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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880886
Report Date: 12/27/2024
Date Signed: 12/27/2024 03:27:03 PM

Document Has Been Signed on 12/27/2024 03:27 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GARDEN OF EDEN ASSISTED LIVINGFACILITY NUMBER:
361880886
ADMINISTRATOR/
DIRECTOR:		VELAZQUEZ, JESSICA AFACILITY TYPE:
740
ADDRESS:14383 CHAMBERLAIN DRTELEPHONE:
(442) 242-7702
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 10DATE:
12/27/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Administrator, Terronsay WhaleyTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 12/27/2024 at 9:40AM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility for a case management visit. LPA introduced self, stated the purpose of the visit and gained access to the residence. LPA met with Administrator Terronsay Whaley and informed Administrator that there are outstanding licensing fees in the amount of $1,237.00 due.

A deficiency was cited.

An exit interview was conducted where this report LIC809, LIC809D and Appeal Rights were discussed and a copy was given to Administrator, Terronsay Whaley.
Karen ClemonsTELEPHONE: (951) 836-2748
Renese Howell-SmallTELEPHONE: (951) 248-2222
DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2024
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
Document Has Been Signed on 12/27/2024 03:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: GARDEN OF EDEN ASSISTED LIVING
FACILITY NUMBER: 361880886

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
87156 Licensing Fees
(a) An applicant or licensee shall be charged fees as specified in...e) The failure of...for licensure... accrued fees and civil penalties shall constitute...denial or forfeiture of a license. This standard was not met as evidenced by:
Deficient Practice Statement
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POC Due Date: 01/03/2025
Plan of Correction
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Licensee/Administrator to pay the balance due by plan of correction due date and submit proof to LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karen ClemonsTELEPHONE: (951) 836-2748
Renese Howell-SmallTELEPHONE: (951) 248-2222

DATE: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2024

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