331881273-2-9-2022-18-AS-VMIN-CBGNZZ-20220209095511

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881273
Report Date: 02/09/2022
Date Signed: 02/09/2022 10:01:33 AM

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
RIVERSIDE, CA 92507

FACILITY NAME:	AVERY GARDEN SENIOR CARE HOME, INC.		FACILITY NUMBER:	331881273
ADMINISTRATOR:	THOMAS, LINDA		FACILITY TYPE:	740
ADDRESS:	26600 IRONWOOD AVE.		TELEPHONE:	(818) 515-9279
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY:	8	CENSUS: 8	DATE:	02/09/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	ADMINISTRATOR LINDA THOMAS		TIME COMPLETED:	11:00 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Venus Mixson, met with administrator Linda Thomas for a Pre-Licensing visit at 26600 Ironwood Ave Moreno Valley CA. 92555. An initial application to operate a Residential Care Facility for Elderly (RCFE) was submitted to the Centralized Applications Bureau (CAB) on Nov.1,2021, for a total eight non-ambulatory beds. Fire Inspection was completed on Dec. 27, 2021, by Moreno Valley Fire Department. LPA observed the following: Structure: Facility was a single-story house with five bedrooms, two bathrooms and two half bathrooms, living room, dining room, family room and kitchen. Heating/Cooling System: Central heating and air conditioning systems. Bedrooms: Bedroom will accommodate non-ambulatory residents only. Bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm. Bathrooms: Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Water temperature measured 110 F. Kitchen/Laundry: Adequate supply of dishes, glasses, utensils, pots, and pans were observed. Cleaning supplies and knives/sharp instruments were secured in a locked drawer. There was adequate room for food storage. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. Seating for meals was adequate. Living/Family room(s): Has adequate seating and furnishings items appear to be in good repair.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0231
LICENSING EVALUATOR NAME: Venus Mixson	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022

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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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
RIVERSIDE, CA 92507

FACILITY NAME: AVERY GARDEN SENIOR CARE HOME, INC.	FACILITY NUMBER: 331881273
	VISIT DATE: 02/09/2022

NARRATIVE

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Hygiene Supplies/Linens: Were adequate in supply, and there were enough linens to change throughout the week if needed.

Outside/Yards: The backyard was completed and had adequate covered area for providing shade. There were no obstructions. There were no bodies of water observed anywhere on the property.

Garage/Storage: The laundry area was near the garage with washer and dryer. Laundry detergents and cleaning solutions were secured in a locked cabinet. Garage was organized and free of obstructions.

Exit Plan/Emergency Phone Numbers: The exit plan was in plain sight mounted throughout the facility. See Something Say Something, Ombudsman, and client’s rights are posted.

General items: Facility has eight (8) first alert / carbon monoxide alarms, that were tested and operational. Additionally, there are ten (10) smoked detectors that are hard wired to the central fire alarm.

LPA observed facility phone and it was verified to be operational by allowing the administrator to call the number (951) 924-3289.

LPA Mixson, reviewed COMPONENT III with the applicant during this Pre-Licensing visit.

An exit interview was conducted for clarity and any questions. A copy of this report was reviewed, signed, and a printed. A copy was left with the administrator Linda Thomas.

The Pre-Licensing visit is completed there are no deficiencies

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0231
LICENSING EVALUATOR NAME: Venus Mixson	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022

LIC809 (FAS) - (06/04)

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