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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426511
Report Date: 07/08/2021
Date Signed: 07/08/2021 10:05:59 AM

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
RIVERSIDE, CA 92507
FACILITY NAME:AVISTA SENIOR LIVING MAGNOLIAFACILITY NUMBER:
336426511
ADMINISTRATOR:SARAH DEVOREFACILITY TYPE:
740
ADDRESS:737 MAGNOLIA AVETELEPHONE:
(951) 737-1600
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY:180CENSUS: 113DATE:
07/08/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Monique Del JuncoTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA), Pauline Beschorner conducted a case management visit to deliver an amended complaint investigation report regarding complaint number 18-AS-20201223164714. The report was reviewed with and provided to Executive Director Monique Del Junco.

Nothing further is needed at this time. An exit interview was conducted and a copy of this report was provided to Executive DIrector Monique Del Junco.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline BeschornerTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
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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