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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800063
Report Date: 01/30/2023
Date Signed: 01/30/2023 11:22:32 AM


Document Has Been Signed on 01/30/2023 11:22 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: 89DATE:
01/30/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Executive Director Stephanie Oden and Resident Care Director Jessica PadronTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 01/30/2023 at 09:10 AM, unannounced for a collateral visit on a complaint investigation to interview residents and staffs regrading complaint control number 56-AS-20220902161328. During this visit LPA Brown was met by facility Executive Director (ED) Stephanie Oden and Resident Care Director Jessica Padron.

An exit interview was conducted, and a copy of this report (LIC809) was discussed and provided to Resident Care Director Jessica Padron.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2023
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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