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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608971
Report Date: 06/12/2024
Date Signed: 06/12/2024 02:01:03 PM

Document Has Been Signed on 06/12/2024 02:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:GARDEN GROVE VILLAFACILITY NUMBER:
197608971
ADMINISTRATOR/
DIRECTOR:		MORALES, NEIL M.FACILITY TYPE:
740
ADDRESS:8051 GARDEN GROVE AVENUETELEPHONE:
(818) 448-6852
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 5DATE:
06/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Jesus De Jesus, StaffTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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At 10:00 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced annual inspection. LPA met with the staff and Administrator contacted and LPA explained the reason for the visit. Administrator arrived at the facility shortly after. LPA and Administrator toured the facility inside and out.

The facility is a single story building with seven (7) bedrooms, four (4) bathrooms, kitchen, dining room, office, garage, storage areas, common areas, and outdoor areas. It has an approved fire clearance for six (6) non-ambulatory residents, of which one (1) may be bedridden. The facility serves residents with dementia. Hospice waivers approved for two (2) residents.

Kitchen: At 10:15, LPA observed that the kitchen contained a freezer, a refrigerator, and two pantries. LPA observed an adequate supply of perishable and non-perishable food. Sharp objects were locked near the stove. Cleaning solutions were locked in a cabinet next to the kitchen.

Medications: Medications were locked near the kitchen in a cabinet. However, LPA observed a full box with seven full bottles of Hair, Skin, and Nail 5,000 mg supplement in bedroom # six (6) in the closet accessible to residents in care. Additionally, LPA observed empty bottles of wine in room # six (6) in the closet.

Bedrooms: The facility has seven (7) private bedrooms. One (1) bedroom is designated as a staff room. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. Bedroom # three (3) and bedroom # five (5) furnishings were clean, odorless, and in good condition. However, Bedroom # one (1), room # six (6), and room # four (4) furnishings and surroundings were not sanitary and clean. In bedroom # six (6), LPA also observed Lysol disinfectant spray bottle almost full accessible to resident in care.

Continue on LIC 809C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GARDEN GROVE VILLA
FACILITY NUMBER: 197608971
VISIT DATE: 06/12/2024
NARRATIVE
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Bathrooms: The facility has four (4) bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At 10:31 AM, LPA measured the water temperature in the shared bathroom to be 117.5 degrees Fahrenheit.

Garage: The garage was locked from the outside. It contained a washer, dryer, paper supplies, extra water bottles, and detergents.

Common Areas: Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At 10:35 A.M. LPA measured the living room temperature to be 76 degrees Fahrenheit. Seating was arranged in the living room to accommodate physical distancing. Extra linens were kept in a storage closet between the kitchen and the staff room.

Safety: At 10:45 AM, LPA observed a fully charged fire extinguisher in the kitchen and was purchased on 10/10/2023. All emergency exit paths were free from obstructions. Exit gates were unlocked. At 10:50 AM, . LPA tested four (4) out of four (4) smoke detectors to be operational. Smoke detectors were hard wired. LPA tested the carbon monoxide detector to be operational. LPA heard four (4) out of four (4) auditory alarms on and functioning during visit.

Outdoor areas: At approximately 11:00 AM, LPA observed staff maintaining the front yard. All outdoor areas were free from debris. A locked shed was located in the back yard. All furniture was clean and in good repair.

Between 12:10 PM to 1:30 PM, LPA reviewed records of five (5) residents and three (3) staff. Residents and staff records appeared to be complete and updated.



Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

Deficiencies cited during today’s visit. Appeal rights explained.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/12/2024 02:01 PM - It Cannot Be Edited


Created By: Huma Rahimi On 06/12/2024 at 12:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GARDEN GROVE VILLA
FACILITY NUMBER: 197608971

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)

f) The following shall be stored inaccessible to residents with dementia: (f) The following shall be stored inaccessible to residents with dementia: (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in two of out two bottles of cleaning supplies and disinfectants sprays in bedroom # four (4) and six full bottles of supplements ordered by the resident in bedroom # six (6), accisseble to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2024
Plan of Correction
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Administrator immediately removed the cleaning supplies as well as the supplements bottles from two resident's rooms. POC cleared during the visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Huma Rahimi
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/12/2024 02:01 PM - It Cannot Be Edited


Created By: Huma Rahimi On 06/12/2024 at 01:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GARDEN GROVE VILLA
FACILITY NUMBER: 197608971

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews, the licensee failed to ensure that the facility is clean, safe, sanitary and in good repair at all times with bedrooms # one (1), four (4), and six (6) not clean and sanitary with a strong odor which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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Administrator agreed to do a deep cleaning for the bedrooms and submit a picture to LPA by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Huma Rahimi
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


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