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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426511
Report Date: 08/23/2024
Date Signed: 08/23/2024 02:37:55 PM


Document Has Been Signed on 08/23/2024 02:37 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:AVISTA SENIOR LIVING MAGNOLIAFACILITY NUMBER:
336426511
ADMINISTRATOR:BLASIA LEE-LOLEFACILITY TYPE:
740
ADDRESS:737 MAGNOLIA AVETELEPHONE:
(951) 737-1600
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY:180CENSUS: 105DATE:
08/23/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Executive Director Kellie SmithTIME COMPLETED:
02:40 PM
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On 08/23/2024 at 01:40 PM, Licensing Program Analysts (LPAs) Melody Brown, Raquel Hernandez and Renese-Howell-Small made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPAs Brown, Hernandez, and Howell-Small met with Executive Director (ED) Kellie Smith and was granted entry to the facility. At the time of the visit there were 105 residents present.

During the visit, ED Smith reported to LPAs Brown, Hernandez and Howell-Small that there are four (4) residents that tested positive for Covid-19 and are isolated. LPAs Brown, Hernandez and Howell-Small informed ED Kellie Smith that the required comprehensive annual inspection will be completed in a later time.

An exit interview was conducted, where this report, LIC809 was discussed and provided to Executive Director Kellie Smith.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024
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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