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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881273
Report Date: 11/07/2023
Date Signed: 11/07/2023 02:47:35 PM


Document Has Been Signed on 11/07/2023 02:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:AVERY GARDEN SENIOR CARE HOME, INC.FACILITY NUMBER:
331881273
ADMINISTRATOR:THOMAS, LINDAFACILITY TYPE:
740
ADDRESS:26600 IRONWOOD AVE.TELEPHONE:
(818) 515-9279
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY:8CENSUS: 8DATE:
11/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Linda Thomas, AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into complaint #18-AS-20231103101819. The LPA met with Administrator, Linda Thomas, and informed her of the purpose for her visit.

During the visit the LPA observed Staff Three (S3) to be in the facility and to be providing transportation to residents. The LPA did not observe S3 to be on the personnel roster. According to Administrator Linda, S3 is a family member who does provide some assistance with tasks in the facility. She reported she has not yet had S3 fingerprint cleared. No background check clearance was observed for S3. Therefore, a citation and civil penalty will be issued.

An exit interview was conducted; this report was reviewed with Linda and a copy was provided, along with LIC 811 and instructions on appeal rights.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 11/07/2023 02:47 PM - 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: AVERY GARDEN SENIOR CARE HOME, INC.
FACILITY NUMBER: 331881273

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2023
Section Cited
CCR
87355(e)

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CRIMINAL RECORD CLEARANCE: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department
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S1 left the facility prior to the end of the LPA's visit.
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This requirement was not met, as evidenced by: Based on observation and interviews, the Licensee did not ensure S3 obtained a California Clearance prior to working in the facility.
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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: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2