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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881454
Report Date: 02/26/2024
Date Signed: 02/26/2024 09:54:29 AM


Document Has Been Signed on 02/26/2024 09:54 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:AVERY GARDEN ASSISTED LIVING-RIVERSIDEFACILITY NUMBER:
331881454
ADMINISTRATOR:THOMAS, LINDAFACILITY TYPE:
740
ADDRESS:7675 WOODVIEW STTELEPHONE:
(818) 515-9279
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY:6CENSUS: 0DATE:
02/26/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Linda Thomas - LicenseeTIME COMPLETED:
10:04 AM
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Licensing Program Analyst (LPA) Sara Martinez conducted an announced visit to complete the Pre-licensing inspection. LPA met with Licensee Linda Thomas, for a Residential Care Facility for the Elderly (RCFE) with a capacity of six (6) residents.

The facility is a five (5) bedroom, four (4) bath home. There are five (5) resident bedrooms, kitchen/dining area, one (1) living room area, a laundry room, attached garage, a detached garage, and a backyard. The facility does not contain any bodies of water or firearms or ammunition. LPA toured the interior and exterior areas of the facility. The following were inspected:

All bedrooms have the required bedding and furniture, such as, clean mattresses/linen, nightstands, dressers, chairs, lighting, and emergency lighting. The bathroom appliances were operating in safe and sanitary condition. The bathrooms have non-slip mats and grab bars. Utensils and dishware are in good repair and ready for client use. Kitchen appliances and counter top were free of debris and in good repair. The knives and sharp objects were locked in the drawers. The water temperature was measured by LPA, the thermometer read at 115 degrees F. There is adequate seating in the common areas. The facility will have a storage locker that will hold resident files and staff files locked in a hallway closet. The facility will have medication locked in a hallways closet.

The facility will keep the detergents and cleaning chemicals in locked cabinets located in the laundry room. An adequate supply of clean linens and hygienic supplies for the residents were readily available at the facility. There are two (2) charged fire extinguishers in the facility. LPA observed operating smoke detectors and carbon monoxide alarms in the facility. LPA observed required postings including the visitation polices, emergency/disaster plans, complaint procedures, and personal rights. The facility was equipped with a complete first aid kit and manual. The facility has working telephone for resident use.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AVERY GARDEN ASSISTED LIVING-RIVERSIDE
FACILITY NUMBER: 331881454
VISIT DATE: 02/26/2024
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LPA observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. LPA has determined that the facility met the operational requirements for licensure. The Pre-licensing inspection is complete, and the facility has no deficiencies. The facility has satisfied all requirements in accordance with Title 22, California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Licensee Linda Thomas.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024
LIC809 (FAS) - (06/04)
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