366427615-9-24-2024-56-AS-JPRO-D9DQRH-20240923122357

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366427615
Report Date: 09/23/2024
Date Signed: 09/24/2024 09:49:31 AM

Document Has Been Signed on 09/24/2024 09:49 AM - 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 CARE		FACILITY NUMBER:	366427615
ADMINISTRATOR:	ADA REYES		FACILITY TYPE:	740
ADDRESS:	6206 WALNUT AVE		TELEPHONE:	(909) 548-0487
CITY:	CHINO	STATE: CA	ZIP CODE:	91710
CAPACITY:	6	CENSUS: 6	DATE:	09/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Administrator Dulce Redford		TIME COMPLETED:	12:30 PM

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Licensing Program Analyst (LPA) Javier Prieto and LPA Becky Mann visited the facility unannounced to complete a comprehensive annual inspection. LPA Prieto met with Dulce Redford Licensee explained the purpose of the visit. Today’s inspection included a facility tour, record review, and interviews with staff and residents.

The facility is four (4) bedrooms and three (3) bathrooms of which one (1) bedrooms are used for residents in care. The facility also has kitchen/dining area, living area, covered patio, and attached garage. Licensed capacity is six (6), and the facility is at maximum capacity.

Physical Plant: There are no obstructions to indoor and outdoor passageways. The facility temperature is 74 degrees Fahrenheit. LPA inspected resident bedrooms; each room included required furniture such as mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were functional. LPA Prieto observed adequate furniture and lighting throughout the facility. The hot water temperature tested at 116.0 degrees Fahrenheit. The facility has operating smoke detectors and carbon monoxide alarms, which LPA Prieto tested during the visit. LPA Prieto observed personal rights posters, Licensing documents, and the disaster plan posted throughout the facility. LPA Prieto observed that cleaning supplies, toxins, sharps, and other dangerous items are kept secure and inaccessible to residents in care. There was a designated storage space for client/staff files. LPA Prieto observed medications locked and inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Last emergency disaster drill was conducted on 07/25/2024.

Food Service: Non-perishable and perishable food supply is sufficient in number for residents in care. The facility has a variety of food available for clients. Dishes, cups, and utensils were also appropriately stored.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

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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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
, CA 92507

FACILITY NAME: GARDEN VILLE HOME CARE	FACILITY NUMBER: 366427615
	VISIT DATE: 09/23/2024

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Care & Supervision: The facility staff is sufficient in number for the care and supervision of residents in care. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPA Prieto reviewed six (6) client files for admission agreements, updated physician reports, and needs and services plans. Medications were audited randomly and appeared to be dispensed appropriately by staff members. Four (4) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings.

No deficiencies were cited during today's visit. LPA Prieto conducted an exit interview with Ms Redford , where a copy of this report was discussed and provided.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

LIC809 (FAS) - (06/04)

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