<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881273
Report Date: 04/02/2024
Date Signed: 04/02/2024 06:01:18 PM


Document Has Been Signed on 04/02/2024 06:01 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:
04/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Linda Thomas, AdministratorTIME COMPLETED:
06:00 PM
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), Stephanie Martinez, conducted a required annual inspection to the facility. The LPA was allowed entrance into the facility and met with Administrator, Linda Thomas. The LPA informed the Administrator of the purpose for the visit. The facility currently has an approved Hospice Waiver for six (6) residents. The inspection included the following:

Physical Plant: The facility consists of five (5) resident bedrooms, one storage space/room, two dinning areas, two living spaces, an open kitchen, a laundry room, a garage space, and a patio with sufficient seating and space for activities. There are no bodies of water located on the property. According to Administrator Thomas, no weapons are stored in the home. The facility is being maintained at a comfortable temperature. All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats or strips present. The carbon monoxide device was tested by the Administrator and was observed to be in operating condition. The Administrator contacted the company that monitors the facility fire alarms; the company reported the alarms are operating in normal condition. The home was kept clean and free of any odors.

Food Service: There is a minimum of 2 days of perishable foods and 1 week's supply of non-perishable foods available.

Record Review: All staff were observed to have appropriate fingerprint clearances. LPA did not observe any excluded individuals on the premises at time of visit. Staff responsible for direct care and supervision have current first aid and CPR training. Dementia care training was observed to be available and complete. The facility was not operating beyond the conditions specified on the license. The LPA was informed by Administrator Thomas there are currently two residents in care who are receiving hospice
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
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


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
VISIT DATE: 04/02/2024
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
26
27
28
29
30
31
32
services. Hospice Care Plans were observed on file at the facility. There is a disaster and mass casualty plan in place. Proof of emergency drills were observed on file. All services requiring specialized skill are being performed by personnel qualified as appropriately skilled professionals.

Medication Review: The LPA reviewed medications for R1. The medications were observed to be well organized and inaccessible to unauthorized individuals.

An exit interview was conducted with Administrator Thomas in which this report was reviewed and a copy was provided. No citations were issued during this visit.

SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2