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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366427615
Report Date: 11/16/2023
Date Signed: 11/16/2023 03:18:33 PM


Document Has Been Signed on 11/16/2023 03:18 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, 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: 6DATE:
11/16/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Dulce Redford, Administrator TIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Javier Prieto arrive to the facility to have administrator Dulce Redford to sign amended complaint report 56-AS-20221121144013 dated 11/29/2022. LPA Prieto and Administrator Redford signed the amended complaint report and this report and a copy was left at the facility.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023
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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