<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366427615
Report Date: 04/27/2021
Date Signed: 04/27/2021 09:54:15 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: 2DATE:
04/27/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Dulce Redford, AdministratorTIME COMPLETED:
10:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to address a violation of Title 22, Division 6, Chapter 8.

On 01/28/21 the LPA conducted an unannounced visit to the facility to conduct a health and safety check. Upon the visit it was observed the facility land line was not receiving calls. According to Administrator Redford, the telephone was in service and would be addressed to ensure proper operation.

Furthermore, the LPA made unsuccessful attempts at contacting Redford via telephone on the following dates: 02/01/2021, 02/02/21, 02/03/2021, 02/24/21. The LPA mailed a letter to the Licensee, on 02/11/21, at the address on file, which was returned to the Department.

Finally, the LPA attempted to contact the facility land line on this date, which again was observed not to be receiving calls. Based on this information a citation will be issued.

This report was reviewed with Redford and a copy provided.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 366427615
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/04/2021
Section Cited

1
2
3
4
5
6
7
TELEPHONES: All facilities shall have telephone service on the premises. This requirement was not met, as evidenced by: Based on observation, the Licensee did not ensure telephone service was on the premises. On 01/28/21 it was observed the facility land line was not receiving calls. The LPA made
8
9
10
11
12
13
14
unsuccessful attempts at contacting Redford via telephone on the following dates: 02/01/2021, 02/02/21, 02/03/2021, 02/24/21. The LPA attempted to contact the facility land line on 04/27/21, which again was observed not to be receiving calls.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2