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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608971
Report Date: 06/12/2025
Date Signed: 06/12/2025 01:41:09 PM

Document Has Been Signed on 06/12/2025 01:41 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: 6DATE:
06/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Neil Morales, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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At 9:50 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced annual inspection. LPA met with the staff Dell Morales AKA Delinia Morales and the the Administrator was contacted via telephone. 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 10:00 AM, 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 and inaccessible to residents in care.

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 clean and appropriate bedding. LPA observed that a resident in room #5 requires incontinence care and a staff approached to change the resident; however, the resident denied to be changed. The Administrator informed LPA that an incident report for the refusal will be submitted to Community Care Licensing Division (CCLD) accordingly.

Continue on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 06/12/2025
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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 10:15 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 10:20 AM. LPA measured the living room temperature to be 75 degrees Fahrenheit. Extra linens were kept in a storage closet in the hallway between bedroom #1 and bedroom #6.

Safety: At 10:30 AM, LPA observed a fully charged fire extinguisher in the kitchen and was purchased on 12/19/2024. In the backyard of the facility LPA observed personal belongings of a resident who exited the facility as of 05/22/2025. The Administrator is safeguarding the personal belongings of the former resident until he/she comes back from their vacation to remove the items. Administrator agreed to submit a plan to LPA of how to securely safeguard the personal belongings of the former resident. All emergency exit paths were free from obstructions. Exit gates were unlocked. At 10:35 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.


Between 12:10 PM to 1:15 PM, LPA reviewed records of four (4) residents and two (2) staff. Residents and staff records appeared to be complete and updated.

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

No deficiencies issued during today’s visit.

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

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025
LIC809 (FAS) - (06/04)
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