Garden Villa

Type of visit: Required - 1 Year

On 09/17/2026, Licensing Program Analyst (LPA) Graham Gunby arrived to the facility unannounced to conduct a Required 1- year annual inspection. LPA was unable to open the CARE tool during this visit. LPA met with the Administrator, Preety Kaur, and explained the purpose of today's visit. The facility is licensed for six (6) non-ambulatory residents, hospice waiver of two (2). LPA was informed there are two (2) residents receiving hospice services. During today's inspection, LPA and Administrator conducted a tour of the interior and exterior of facility to ensure the health and safety of residents in care. Areas toured included but not limited to: residents bedrooms, bathroom, kitchen, backyard and the common areas. LPA observed medication and sharps to be locked and secured. LPA observed cleaning solutions and disinfectants unlocked and accessible to residents in care. LPA observed fire extinguishers to be last serviced on 02/10/2026. Water temperature was measured in the kitchen sink at 117.3 degrees Fahrenheit. LPA reviewed six (6) residents files and three (3) staff files. Three (3) of six (6) resident records did not contain all required documentation. Staff files did not contain current and up-to-date CPR/First Aid training. Deficiencies are being cited during today's visit on LIC809-D Exit interview conducted and a copy of the report will be emailed to Administrator.the state’s words, verbatim · CDSS document, Sep 17, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Sep 18, 2026

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Based on LPA's observation, facility did not ensure that cleaning products and disinfectants were inaccessible to residents in care, which poses an immediate health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Sep 17, 2026

Plan of correction: Facility will ensure that all hazardous items are locked and inaccessible to the residents in care at all times. Administrator will complete a statement of understanding regarding regulation 87309 and submit to LPA by POC due date of 09/18/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87623(b)(2) · Plan of correction due date: Oct 17, 2026

87623(b)(2) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that the bag and tubing are changed by an appropriately skilled professional should the resident require assistance. This requirement was not met as evidenced by: Based on LPA's review of records and statements by the Administrator, the Licensee failed to ensure catheter bag for R5 was changed by an appropriately skilled professional.the state’s words, verbatim · CDSS document, Sep 17, 2026

Plan of correction: The Administrator shall develop policies and procedures for the care of residents with indwelling catheters which complies with the requirements of 87623. Administrator shall coordinate a skilled professional to train facility staff for this procedure. The policy shall be emailed to LPA by 10/17/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87629(b)(1) · Plan of correction due date: Oct 17, 2026

87629 Injections. (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensees who admit or retain residents who require injections shall be responsible for the following: (1) Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above due to facility not having a diabetic management plan along with R3’s 602 stating they cannot perform their own injections or glucose monitoring which poses an potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 17, 2026

Plan of correction: Administrator to send into LPA a copy of their plan for diabetic residents going forward. Administrator will coordinate a skilled professional to provide staff with training regarding injections and glucose monitoring. Plan to be emailed to LPA by 10/17/26.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.618(c)(3) · Plan of correction due date: Oct 17, 2026

Administration/Management- Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. LPA did not observe any CPR cards in files for S1 during visit. Administrator acknowledged that one staff had a CPR card but it was not at the facility. It was stated working staff have CPR training, but could not provide confirmation.the state’s words, verbatim · CDSS document, Sep 17, 2026

Plan of correction: Administrator agreed to immediately schedule staff to attend CPR training. Administrator also agrees to have one staff person on site at all times with a CPR card. Administrator will send to CCL a copy of staff CPR cards by 10/17/2026.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 9/9/25 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator, Preety Kaur, arrived to assist LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. 3 resident and 2 staff files were reviewed. Files are complete Dementia regs changes discussed. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Sep 9, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 9/24/24 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator, Preety Kaur, arrived to assist LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and licensee discussed leaving hallway fire door unobstructed as well as pending repair to roof on the rear of the house. 5 resident and 2 staff files were reviewed. Licensee to send missing documents to LPA. Additionally, licensee will send: Infection Control Plan, Emergency Plan, LIC 500, Resident roster, liability insurance and LIC 308s is applicable. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Sep 24, 2024

Allegation investigated: Staff does not ensure resident is allowed to have visitors.

On 8/7/24, Licensing Program Analysts (LPA) Kevin Mknelly and Graham Gunby conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with designee caregiver. LPA soke with the Administrator by phone. LPA conducted records review and extensive interviews. LPA is unable to find and or meet the preponderance, per policy. On or about 4/14/24, R1 made a phone call to family. Reportedly R1 made statements to family that R1 was placed in the home against R1’s wishes and that R1 is being denied visits and phone access. R1 was interviewed by the Ombudsman and reportedly made similar statements that R1’s spouse was limiting access by R1 to R1’s sister and daughter. LPA interviewed R1, R1’s wife, R1’s sister and the Ombudsman during the course of the investigation. Report continued Unsubstantiated Records review for R1 found R1 to be diagnosed by R1’s primary physician as having Alzheimer's and bi-polar disorder. On 5/7/24, LPA interviewed R1. R1 stated that R1 is not being held against his will at the facility and that for the time being R1 does not wish to have calls or visits while R1 is focused on getting better. R1 stated to LPA that he does not know why R1 made those previous statements. On 5/7/24, LPA interviewed the Administrator. Administrator stated that R1 knew that R1 could make phone calls from the facility phone. After R1 took the phone of another resident to call R1’s family on 4/14/24, Administrator asked R1 why R1 did not ask for the facility phone. R1 reportedly stated that R1 did not know why R1 did that. Between 5/7/24 and the conclusion of this investigation, attempts by family to call or write to R1 were told to R1 and mail was delivered to R1 and R1 chose to not respond to family contact. The investigation found that while R1 at times made conflicting statements regarding his wishes or the wishes of others, conclusive evidence was not presented that the facility restricted R1’s right to visits, calls or personal mail. R1 has since moved out of the facility. As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview with designee, Mario Lantao and report provided.the state’s words, verbatim · CDSS document, Aug 7, 2024 · control 59-AS-20240425134600