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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426511
Report Date: 08/23/2022
Date Signed: 08/23/2022 11:09:52 AM


Document Has Been Signed on 08/23/2022 11:09 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:AVISTA SENIOR LIVING MAGNOLIAFACILITY NUMBER:
336426511
ADMINISTRATOR:MONIQUE DEL JUNCOFACILITY TYPE:
740
ADDRESS:737 MAGNOLIA AVETELEPHONE:
(951) 737-1600
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY:180CENSUS: DATE:
08/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Blasia Lee-Lole, Executive DirectorTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Amy Goldenberg is conducting this case management visit for the purpose of a health and safety check. LPA conducted a tour of the facility and grounds, assessing the physical plant, staffing, food supply, and general care of residents. Residents are present during this tour engaged in various activities of choice. Sufficient staff are present at the facility to provide care. LPA observed three (3) days supply of perishable and seven days (7) supply of non-perishable food. No imminent health and/or safety concerns identified at the time of this visit

This report was reviewed with and a copy was provided to the facility representatives during the exit discussion.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
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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