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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366427615
Report Date: 11/08/2021
Date Signed: 11/08/2021 02:41:49 PM

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:
11/08/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:54 PM
MET WITH:Dulce RedfordTIME COMPLETED:
02:50 PM
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
Licensee Program Analyst (LPA'S), Bernadette Allen and Anna Bueno, conducted an unannounced visit to the facility to obtain information on the current status of the home.
The Department received information indicating the Licensee has failed to make rental payments, which has resulted in a pending eviction. There is a scheduled eviction for 11/9/2021 at 6:00 AM. The Licensee and LPA'S discussed relocation plan for the residents. The licensee has no plan in place for relocation to date but plans to pay the total amount due for rent today 11/8/2021. The licensee was informed that proof of payment to the CDSS is required. There are no current health and safety concerns. No deficiencies were cited.
An exit interview was conducted and this report was provided to the licensee.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: (951) 897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
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 1