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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800063
Report Date: 05/12/2022
Date Signed: 05/12/2022 10:23:30 AM


Document Has Been Signed on 05/12/2022 10:23 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:GARDENS OF RIVERSIDE, THEFACILITY NUMBER:
331800063
ADMINISTRATOR:STEPHANIE ODENFACILITY TYPE:
740
ADDRESS:10849 ARLINGTON AVETELEPHONE:
(951) 637-8844
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY:98CENSUS: 86DATE:
05/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Stephanie OdenTIME COMPLETED:
10:28 AM
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility regarding complaint number 56-AS-20220429113617. LPA Gardner met with Administrator Stephanie Oden and explained the reason for the visit.

LPA Gardner visited the facility to obtain a signature for an amended report.

An exit interview was conducted where this report was discussed and provided to the with Administrator Stephanie Oden.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
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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