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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880531
Report Date: 05/19/2023
Date Signed: 05/19/2023 11:25:09 AM


Document Has Been Signed on 05/19/2023 11:25 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:AVERY GARDEN ASSISTED LIVING INC.FACILITY NUMBER:
331880531
ADMINISTRATOR:THOMAS, LINDAFACILITY TYPE:
740
ADDRESS:5377 FULMER COURTTELEPHONE:
(951) 934-3140
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
91752
CAPACITY:6CENSUS: 6DATE:
05/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:03 AM
MET WITH:Linda Avery, Administrator/LicenseeTIME COMPLETED:
11:45 AM
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This is a case management visit conducted by Licensing Program Analyst (LPA) Amy Goldenberg. During this visit LPA conducted a health and safety check. The facility has food, water and electricity. LPA toured the facility and learned that six (6) residents reside in the home. The purpose of this visit is to follow up on the status of resident (R1). LPA reviewed one hospice record for R1 and learned the following: R1's postural supports are supported by hospice services in place. All bedrooms have a bedridden fire clearance approval.
Based on LPA review of the records and tour of the facility, there are no deficiencies being cited per Title 22, Division 6 of the California Code of Regulations on this date. LPA reviewed this report with Linda Avery, Administrator/Licensee and provided her with a copy.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023
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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