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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366427615
Report Date: 12/22/2021
Date Signed: 12/22/2021 03:13:25 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:
12/22/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:26 PM
MET WITH:Dulce RedofrdTIME COMPLETED:
03:14 PM
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Licensing Program Analyst (LPA) Anna Bueno made an unannounced plan of correction (POC) to verify corrections of citations issued on a previous visit. LPA was met by licensee Dulce Redford who was informed the reason of the visit.

The following deficiency were not corrected from the POC due date 11/23/21 until today.
Deficiency cited under California Code of Regulations Title 22, Section 87211(d)(4), the licensee shall notify the Department, the State Long-Term Care Ombudsman, all residents, and, if applicable, their representatives, in writing within two business days of any of the following specified events, or knowledge thereof: The licensee receives a written notice of default of payment of rent described in Section 1161 of the Code of Civil Procedure.

During today's visit, licensee stated that an eviction letter was drafted on 11/8/21 and all responsible parties were verbally notified by phone between 11/8/21 and 11/12/21. Licensee stated printed copies were not provided to any responsible party. LPA received an emailed copy of the 60 day eviction notice on this day. Civil penalty of $2900 is assessed for the period 11/24/21 through 12/22/21.

Refer to LIC809D issued on 11/22/21 for deficiency cited. An exit interview was conducted where this report, LIC421FC, and appeal rights were discussed and provided to the licensee.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
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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