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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603542
Report Date: 05/15/2025
Date Signed: 05/15/2025 01:35:03 PM

Document Has Been Signed on 05/15/2025 01:35 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GARDENIA GARDEN, INCFACILITY NUMBER:
198603542
ADMINISTRATOR/
DIRECTOR:		MELIKYAN, SONAFACILITY TYPE:
740
ADDRESS:1708 ROYAL OAKS DR.TELEPHONE:
(626) 772-3050
CITY:DUARTESTATE: CAZIP CODE:
91010
CAPACITY: 6CENSUS: 5DATE:
05/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:29 AM
MET WITH:Marebeth Mallare - AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Bennette Pena and Gabriela Castro conducted an unannounced Required-1 year visit. LPAs were met by Marebeth Mallare, Administrator and Leonardo Mallare, Caregiver and explained the purpose of the visit. The facility cares for residents age range 60 and over and licensed for (5) non ambulatory, (1) bedridden resident (shall be in bedroom #3), and approved for (6) hospice residents only. There are currently (3) residents on hospice. LPAs utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Staff are trained on the emergency infection control plan and following hand hygiene techniques. Emergency and disaster plan was completed and up to date.


Operational Requirements: The Infection Control Plan has been reviewed and updated. A Hospice Waiver for (6) is approved. Liability insurance policy is in place and expiring on 06/19/2025. The facility does not handle cash resources for the residents. Latest fire drill was conducted on 03/01/2025.
Physical Plant/Environment Safety: The facility is a single story home located in a residential community.
The home consists of living room, dining area, kitchen, (4) resident bedrooms, one of the bedrooms has a fireplace that is adequately screened, (4) bathrooms, back yard with swimming pool that is fenced and inaccessible to residents, and laundry area in the attached garage. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. Bathrooms have the required grabs bars and non-skid materials. The laundry room is clean and has cleaning supplies inaccessible to residents. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are cleaning and are working properly. The common areas such as activity room and dining room are clean and have the required furniture. The backyard has a shaded area and sitting area. There is also a swimming pool in the backyard Exit doors have auditory devices that were operating at the time of the visit. There are cameras in the front door, backyard, living room, dining area and kitchen. There were no cameras seen in private areas. Exit doors are free of any obstruction. Cleaning supplies and toxic substances are inaccessible to residents. The facility has (3) fully charged fire extinguishers, last serviced on 01/15/2025.*****CONTINUED ON LIC809-C*****
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2025
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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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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GARDENIA GARDEN, INC
FACILITY NUMBER: 198603542
VISIT DATE: 05/15/2025
NARRATIVE
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Staffing: A total of three (3) caregivers including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility.
Personnel Records-Training: Three (3) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings. Administrator has completed the required Administrator courses but has not submitted the certification renewal.
Resident Rights-Information: Resident personal rights are posted. Visiting policy is posted at a location that is visible and accessible to residents and families. Physician orders for use of full/half bed rails were reviewed in residents files. LPAs conducted (3) resident interviews.
Planned Activities: Information regarding Dementia is part of training for direct care staff and is included in the Plan of Operation. The facility provides sufficient space to accommodate both indoor and outdoor activities.
Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Plates, cups and utensils are kept cleaned and stored properly.
Incident Medical and Dental: All residents have Restricted Health Care Plan and Needs and Services Plan on file. Home Health personnel services the residents in the facility. Hospice and Home Health Nurses conduct visits on a regular basis. (5) residents' medications were reviewed with no issues observed.
Resident Records-Incident Reports: Five (5) resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records,
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, operation of manual assist devices. The facility conducts emergency drill on a quarterly basis for all staff and residents.
Residents with SHN: (3) Residents are on hospice and palliative care.


Per California Code of Regulations, Title 22, deficiencies were cited. An exit interview was conducted and a copy of the report and appeal rights were provided to the Administrator, Marebeth Mallare.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/15/2025 01:35 PM - It Cannot Be Edited


Created By: Bennette Pena On 05/15/2025 at 01:17 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GARDENIA GARDEN, INC
FACILITY NUMBER: 198603542

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, the Administrator did not comply with the section cited above in that the facility does not have the proper Medication Administration Record (MAR) to document the residents' medication which poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 05/16/2025
Plan of Correction
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Administrator agreed to complete a Medication Administration Record (MAR) for each resident and submit a copy to CCL/LPA by POC 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/15/2025 01:35 PM - It Cannot Be Edited


Created By: Bennette Pena On 05/15/2025 at 01:17 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GARDENIA GARDEN, INC
FACILITY NUMBER: 198603542

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87606(b)
Care of Bedridden Residents
(b) A licensee shall notify the fire authority having jurisdiction within 48 hours of accepting or retaining any person who is bedridden, as specified in Health and Safety Code section 1569.72.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, the Administrator did not comply with the section cited above in that the facility currently has 2 bedridden residents but only has fire clearance approved for (1) bedridden resident which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 05/23/2025
Plan of Correction
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Administrator agreed to contact the fire department to notify of the 2nd bedridden resident and send proof of notification to CCL/LPA by POC 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2025


LIC809 (FAS) - (06/04)
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