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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366427615
Report Date: 11/29/2022
Date Signed: 11/16/2023 03:19:02 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/21/2022 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20221121144013
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: 4DATE:
11/29/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator Dulce RedfordTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff were not present at the facility.

Uncleared adult at the facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Javier Prieto made an unannounced visit to investigate and deliver findings for the allegations listed above. LPA stated the purpose of the visit and was granted entry and met with Administrator Dulce Redford. The investigation consisted of a facility tour, resident interviews, staff interviews, and document review.

For allegation, Facility staff were not present at the facility:
Interviews with staff and documentation obtained was revealed when Redford produced copies of staff records showing staff #1 (S1), who was present during time of initial complaint visit, as the facility manager/DSP, with records that S1 is fingerprint cleared. Fingerprint cleared records were obtained during today's visit with documentation of S1 title and relationship to the facility.

For allegation, uncleared adult at the facility: Fingerprint clearance records were also obtained for adult present at the facility during time of initial complaint visit. Fingerprint cleared adult is required to be fingerprinted and cleared in relation to being a family member over the age of 18 years. Records of this clearance were obtained by LPA during time of visit.

This agency has investigated the complaint alleging that facility staff were not present at the facility and uncleared adult at the facility. We have found that the complaint was UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/21/2022 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20221121144013

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: 4DATE:
11/29/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator Dulce RedfordTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not ensure that residents are adequately fed.

Facility staff did not properly store residents' medications in a separate locked area.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Javier Prieto made an unannounced visit to investigate and deliver findings for the allegations listed above. LPA stated the purpose of the visit and was granted entry and met with Administrator Dulce Redford. The investigation consisted of a facility tour, resident interviews, staff interviews, and document review.

For allegation, Facility staff did not ensure that residents are adequately fed:
Redford produced the "meal and lodging" and "meal periods" from resident #1 (R1) admission's agreement reveal that the resident is being appropriately fed with special conditions of food being cut in small portions. Tour of the facility shows a sufficient amount of perishables and non-perishables to feed all residents at the facility.

For allegation, Facility staff did not properly store residents' medications in a separate locked area: Redford showed LPA the kitchen cabinet, which stores resident medications, to be locked and inaccessible to residents at the home. Staff #1, demonstrated the locking mechanism with a key that only staff can obtain.

Based on the information obtained there is not enough evidence that facility staff did not ensure that residents are adequately fed and facility staff did not properly store residents' medications in a separate locked area. Therefore, the allegations are deemed UNSUBSTANTIATED at this time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2