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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366427615
Report Date: 01/28/2021
Date Signed: 04/27/2021 09:05:58 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:GARDEN VILLE HOME CAREFACILITY NUMBER:
366427615
ADMINISTRATOR:ADA REYESFACILITY TYPE:
740
ADDRESS:6206 WALNUT AVETELEPHONE:
(909) 548-0487
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY:6CENSUS: 3DATE:
01/28/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Dulce Redford, LicenseeTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced Health and Safety visit to the home. The visit was conducted after it was report the home has not paid for one (1) month of rent and is late in paying Annual Licensing fee's. The LPA met with Licensee, Dulce Redford, and informed her of the purpose of her visit.

The LPA conducted a virtual tour of the home, due to the COVID-19 pandemic. The LPA observed perishable and non-perishable food available and the utilities to be in working order. The LPA conducted a resident tele-interview; no concerns were reported.

No health and safety concerns were observed on this visit. This report was reviewed with Redford and a copy was provided via email.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2021
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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