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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880886
Report Date: 10/07/2023
Date Signed: 10/07/2023 12:55:09 PM


Document Has Been Signed on 10/07/2023 12:55 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:GARDEN OF EDEN ASSISTED LIVINGFACILITY NUMBER:
361880886
ADMINISTRATOR:VELAZQUEZ, JESSICA AFACILITY TYPE:
740
ADDRESS:14383 CHAMBERLAIN DRTELEPHONE:
(442) 242-7702
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY:6CENSUS: 7DATE:
10/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Angelica Villareal, Caregiver/StaffTIME COMPLETED:
01:15 PM
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Licensing Program Analyst, Amber Coleman, (LPA) made an unannounced case management visit to deliver findings and obtain signatures for an amended report. LPA met with staff, introduced self and stated purpose of the visit. LPA obtained signatures and completed report.

At approximately, 1:00pm LPA conducted a walk through of the facility's second floor. LPA observed that the facility's fire extinguisher was last inspected January 2021. A Technical Violation will be cited, as the fire extinguisher is fully charged.

An exit interview was conducted where this report was discussed and provided to facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2023
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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