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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880531
Report Date: 10/27/2022
Date Signed: 11/07/2022 09:00:14 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/07/2022 09:00 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:
10/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Linda Thomas,
Sayla Groehler, Caregiver
TIME COMPLETED:
04:00 PM
NARRATIVE
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 Licensing Program Analysts (LPAs) Amy Goldenberg and Amber Coleman and made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. The facility has an approved mitigation plan on file with this agency. Precautionary Covid-19 postings are present at the front door and at the entry point. There is one entry point designated where sign in procedures and screening occur. The staff are symptom/temperature screening visitors upon entry into the facility. LPA observes that all staff are wearing face masks. LPA is informed that there are no positive cases of Covid-19 at this time. There are six (6) residents present at the time of the visit, of which two (2) are receiving hospice services. LPA conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. The facility was equipped with sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and a 30 day supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in infection control. The facility continues to monitor client regularly for any changes in condition, and notify the client's physician and emergency personnel in the event the client presents any COVID-19 symptoms. Water temperature measured 101-110.9 degrees F. Emergency food supply is in place. LPA inquired about fit testing and found that the employees have not been fit tested for N95 respirators. Technical assistance provided during this visit. LPA observed that R1 has full bed rails on their bed. R1 is not on receiving hospice services. Based on observations made during today’s inspection, the following deficiency cited per Title 22, Division 6, of the California Code of Regulations. LPA reviewed this report with and a copy was provided to the facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
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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Document Has Been Signed on 11/07/2022 09:00 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
10/28/2022
Section Cited
CCR
87608(a)(5)

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Bed rails that extend the entire length of the bed are prohibited except for residents .... hospice care and have a hospice care plan that specifies the need for full bed rails.The facility has not met
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Licensee will discuss with R1's physician alternative saftey measures for R1 by POC due date 10/28/22 and provide in writing discussed changes and plan of compleation to CCL.
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 this requirement as evidenced by LPA observed that R1 has full bed rails on their bed. R1 is not on receiving hospice services. This poses a risk to the health and safety of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
LIC809 (FAS) - (06/04)
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