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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802287
Report Date: 10/07/2024
Date Signed: 10/07/2024 01:27:45 PM

Document Has Been Signed on 10/07/2024 01:27 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GARDEN VIEW INNFACILITY NUMBER:
405802287
ADMINISTRATOR/
DIRECTOR:		KOC DE JONG, DIMFNAFACILITY TYPE:
740
ADDRESS:7105 SAN GABRIEL RDTELEPHONE:
(805) 462-2273
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 15CENSUS: 13DATE:
10/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:37 AM
MET WITH:Administrator - Dimfna Koc de Jong TIME VISIT/
INSPECTION COMPLETED:
03:38 PM
NARRATIVE
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 At 11:40am on 10/07/2023, Licensing Program Analyst (LPA) Jeffries arrived at the facility to conduct and unannounced annual inspection visit. LPA met with Administrator Dimfna Koc de Jong announced who he is and the reason for the visit.

The facility consists of a two-story house on a large property. The first level of the house consists of a dining room, sitting room, office, warming/staff kitchenette, a family room, 5 resident bedrooms and 2 bathrooms. The second level of the house consists of the living room, family room, dining room, main kitchen, laundry room, 4 bedrooms and 2 bathrooms. There is a deck off of the upstairs dining room and a ramp leads outside to the first floor. The facility has a swimming pool and spa that are gated and locked per regulation requirements. There are several outdoor areas with appropriate furniture and shade available. LPA toured facility with Administrator. LPA noted concerns with facility floor having several areas where the floor is causing spacing between the tile, which the facility is addressing as needed. LPA also noted that a closet on the top floor has evidence of water leakage. Based on the water leakage and the repairs that were addressed of the facility floor LPA will issue a citation of, 87303(a) for the facility to be in good repair at all times and request that Administrator have a structural engineer assess the integrity of the facilities structure in a timely manner. The facility is maintained in conformance with state fire marshal regulations. Smoke detectors and carbon monoxide detectors functioning throughout the facility. There is a sprinkler system in the ceiling of facility that was last pressure tested by Mid Coast Fire on 07/16/2024, billed to Dave Clark of Atascadero Mutual Water Company. Fire extinguishers were fully charged. Inside and outside passageways are free from obstruction. The facility temperature was 72 degrees F. Hot water temperature tested and within regulation parameters. Residents’ rooms are appropriately furnished with adequate lighting. LPA observed more than two days of perishable and more than seven days of non-perishable food. Food is stored in proper containers in the refrigerators and freezers. LPA reviewed Emergency Disaster Plan, Infection Control Plan, staff and resident files, training records and centrally stored medication records. LPA noted that facility last conducted and documented an emergency evacuation dill on May 8th, 2024, which is past due on the quarterly requirements required by regulations (1569.695(c)), citation issued.

CONTINUED on LIC9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2024
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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Document Has Been Signed on 10/07/2024 01:27 PM - It Cannot Be Edited


Created By: Mark Jeffries On 10/07/2024 at 12:51 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GARDEN VIEW INN
FACILITY NUMBER: 405802287

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)


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 floor repairs and evidence of water damage which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
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Licensee agrees to have Strutural Engener (SE) assess the facility building for structral integrety and report to LPA by email of evidence of the SE evlauation of the facilit.
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:Kelly Burley
LICENSING EVALUATOR NAME:Mark Jeffries
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024


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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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GARDEN VIEW INN
FACILITY NUMBER: 405802287
VISIT DATE: 10/07/2024
NARRATIVE
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 Licensee and LPA conducted a full review of the annual control tools. LPA noted no other violations or citations issued aside from the two mentioned above.

Exit interview, report read, appeal rights, and report provided.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/07/2024 01:27 PM - It Cannot Be Edited


Created By: Mark Jeffries On 10/07/2024 at 01:18 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GARDEN VIEW INN
FACILITY NUMBER: 405802287

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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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:Kelly Burley
LICENSING EVALUATOR NAME:Mark Jeffries
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024


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