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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803663
Report Date: 05/26/2022
Date Signed: 05/26/2022 09:55:51 AM

Document Has Been Signed on 05/26/2022 09:55 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:GARDEN HOMEFACILITY NUMBER:
216803663
ADMINISTRATOR:ZHU, XIAOTONG "SHERRY"FACILITY TYPE:
740
ADDRESS:16 GARDEN AVETELEPHONE:
(415) 350-6636
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 4CENSUS: 4DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Care Giver #1, Elsa BacsalTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Garden Home for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Care Giver #1, Elsa Bacsal and was granted access into the facility. Upon entry into the facility, LPA observed Care Giver #2 and #3 not wearing a mask (See LIC 809D). Facility Manager, Tom Yuan arrived 30 minutes later.

LPA toured the facility with Care Giver #1. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on April 2022 at the time of the inspection. Facility smoke detectors and carbon monoxide were found to be functioning properly at the time of the visit. Hot water temperature measured at 105 degrees within Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 client’s bathroom while touring facility. There was a supply of both perishable and non-perishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the inspection. Toxins are stored in a locked cabinet under the kitchen sink. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. The bathroom designated for clients at the facility were supplied with individual paper towels; hand soap dispenser was available. All client’s bedrooms have lighting & appropriate furnishings.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored in the garage. Facility staff has not been N95 Fit tested (See LIC 9102)

(Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: GARDEN HOME
FACILITY NUMBER: 216803663
VISIT DATE: 05/26/2022
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LPA requested the following documents to be sent to CCL:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610D)
Surety Bond (if any)
Most up-to-date Liability insurance
Control of Property
Register of Residents

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 Chapter 8 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights were provided.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/26/2022 09:55 AM - It Cannot Be Edited


Created By: Farhaan Sarangi On 05/26/2022 at 09:17 AM
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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GARDEN HOME
FACILITY NUMBER: 216803663

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(3)(B)
On May 26, 2022, facility failed to protect the personal rights of clients in care to receive safe and healthful accommodations and engaged in conduct inimical to the health, welfare, and safety of clients in care, in that Care Giver #2 and 3 failed to wear face coverings while providing care and supervision to clients in care*, in violation of official government orders requiring the wearing of face coverings while working under specified conditions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the facility did not comply with the section cited above in 2 out of 3 Care Givers were not wearing masks which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2022
Plan of Correction
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Facility shall train staff on the Infection Control Mitigation Plan that was submitted to CCL and provide a statement on how future compliance will be met along with a sign-in sheet.
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022


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