Garden of Eden Guest Home

Allegation investigated: Bedbound resident sustained a leg fracture and staff deny knowledge of injury.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Staff #1 (S1) Yuriel Jimenez on behalf of Administrator (AD) Claudia Olteanu and explained the reason for today’s inspection. The investigation into the allegation that a bedbound resident sustained a leg fracture and staff deny knowledge of injury revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, staff, and residents, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) medical records, and a letter from R1’s doctor. CONTINUED Unsubstantiated It was alleged that on July 7, 2021, R1, who is bedbound and requires total care, was brought to the hospital, diagnosed with a left distal spiral femur fracture, and facility staff were unable to explain how R1 sustained the fracture. LPA interviewed AD who stated that on July 2, 2021, R1 was seen by their doctor at the facility who found no issues with R1, then on July 7, 2021, staff noticed swelling on R1’s knee and took R1 to the hospital where they were diagnosed with a fracture, and AD does not know how R1 sustained the fracture. Per AD, R1 is sensitive to movement, so the facility uses two staff to transfer R1 using a Hoyer lift, and due to the risk of bed sores R1 is repositioned every two hours. AD stated that no bruising or visible injury was observed at the site of the fracture and that R1 had a long-standing small fracture in the same location as the fracture diagnosed on July 7, 2021. LPA attempted to interview R1, but R1 is non-verbal. LPA inspected the facility, conducted health and safety checks on R1 and the other four residents, and observed no health and safety issues. LPA interviewed the other four residents, two of whom were unable to participate in the interview, and two of whom reported no concerns with the care provided at the facility. LPA interviewed three staff who provided care to R1, none of whom were able to identify any falls or injuries that could have caused the fracture. Review of R1’s medical records revealed that R1 has a history that includes a chronic left humerus fracture and chronic hip/pelvic fractures. Per R1’s medical records, on July 7, 2021, R1 was diagnosed with an acute, comminuted displaced fracture of the femoral diaphysis, R1 was noted to have weakened and brittle bones, and follow up was recommended to exclude a pathological fracture resulting from weakened bones that can easily break after a minor injury that would not normally cause serious damage. Per a letter from R1’s doctor, R1’s bone condition places R1 at risk for fractures after low energy trauma including twisting and/or bumping the extremities while seated in their chair. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jun 23, 2026 · control 22-AS-20210714155439

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Claudia Olteanu and discussed the purpose of the visit. The facility is a one story home with six resident bedrooms, three bathrooms, one staff room, living room, kitchen, dining room, laundry room and two car garage. The facility appears clean, safe and sanitary. LPA observed all the bedrooms to have the required components and furnishings. LPA observed the bathrooms to have toilet paper, paper towels and non slip mats in the shower. LPA tested the water to be between 107.7 and 107.9 degrees Fahrenheit. LPA observed the kitchen to be clean and free of vermin. The facility has a two day perishable and seven day non perishable food supply on hand. The sharps are locked in a kitchen drawer and made inaccessible. The centrally stored medication is stored in a locked kitchen cabinet and made inaccessible. The first aid kit was found to be in a cabinet in the kitchen and had all the required components. LPA observed fire extinguishers throughout the facility charged and with a service date of January 6, 2026. LPA observed the garage to be used as a staff office and for extra facility storage. LPA observed an extra food supply on hand in the garage. LPA observed the toxins and chemicals to be in a locked cabinet in the garage and made inaccessible. Clean linens are stored in the garage for resident use. The emergency food and water supply was located in the garage as well. The backyard was free of debris and obstructions. LPA observed a shaded seating area for resident enjoyment in the backyard. AD tested the carbon monoxide and smoke detectors and they were found to be operational. LPA observed the staff bedroom to be locked and made inaccessible to residents in care. Continue on LIC809C LPA reviewed staff files and no issues were observed. LPA reviewed resident files and no issues were observed. LPA reviewed resident medications and no issues were observed. LPA and staff reviewed P&I and all monies were accounted for. LPA reviewed that the last fire drill was conducted on May 21, 2026. All staff present are background cleared and associated to the facility. LPA provided Legionnaires' Disease Fact Sheet at the time of the inspection. Based on today's observations no deficiencies are being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jun 17, 2026

Type of visit: Required - 1 Year

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Staff #1 (S1) Mylene Manze and discussed the purpose of the inspection. Administrator (AD) Claudia Olteanu appeared via telephone. LPA reviewed Infection Control requirements. At about 11:30AM, LPA and S1 conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 7-bedroom, 3-bathroom, one-story house with an attached garage that is used for storage. There is a back yard with a patio cover for the residents. LPA observed 3 staff and 6 residents present at the facility in addition to S1. Resident Bedrooms: the 6 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: LPA inspected the one staff bedroom. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 110 and 115 degrees F in the 2 resident bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the garage. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are not yet due. At about 12:30PM, LPA reviewed 6 resident files and 4 staff files, interviewed 2 residents and 2 staff, inspected medications for 6 residents, and inspected resident money and ledgers for 6 residents. There were no deficiencies observed in the areas inspected. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jul 15, 2025

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

This unannounced inspection is being conducted by Licensing Program Analysts (LPAs) Sean Haddad and William Vanegas for the purpose of conducting a Required – 1 Year Inspection. LPAs met with Staff #1 (S1) Christine Alfaro and discussed the purpose of the inspection. Administrator (AD) Claudia Olteanu appeared via telephone. LPAs reviewed Infection Control requirements. At about 2:15PM, LPAs and S1 conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 7-bedroom, 3-bathroom, one-story house with attached garage that is used for storage. There is a back yard with a patio cover for the residents. LPAs observed 4 staff and 4 residents present at the facility. Resident Bedrooms: the 6 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: LPAs inspected the 1 staff bedroom. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 111 degrees F in the common resident bathroom and 107 in the private resident bathroom. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in kitchen. Toxins: observed locked in the storage closet. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 3:00PM, LPAs reviewed 6 resident files and 4 staff files, interviewed 2 residents and 2 staff, inspected medications for 6 residents, and inspected resident money and ledgers for 6 residents. CONTINUED During the inspection, LPAs and S1 observed the following: based on documents and admission, the licensee corporation is suspended; and based on documents, the facility has been using Regional Center admission agreements and does not have their own admission agreement executed with any of the 6 residents. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jul 25, 2024