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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366427615
Report Date: 02/04/2022
Date Signed: 02/04/2022 04:16:49 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:
02/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Alvin Dela Cruz, staffTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced case management visit to this facility. The purpose of this visit is to address the licensee’s failure to provide requested information and/or supporting documentation for a solvency audit conducted by Community Care Licensing (Department) auditor. Upon arrival, LPA met with staff Alvin Dela Cruz and was informed of the reason for today’s visit. LPA phoned the licensee who informed LPA that they were not able to come to the facility.

The Department requested a solvency audit of this facility due to information received by the Department and complaint investigation observations that indicate the Licensee has been failing to make timely rental payments, which has resulted in a pending eviction. The Auditor requested financial statements, including the monthly operating statement (LIC 401), supplemental financial information (LIC 401a) and the balance sheet (LIC 403 and LIC 403a). Additionally, the auditor requested supporting documentation such as, facility utility statements, bank statement, credit card statements, federal income tax returns, payroll quarterly filings, food receipts, rental agreements, proof of liability insurance coverage, and employee roster and their schedules and other documentation that supported the revenues, expenses, and assets reported by the licensee.

The Licensee failed to submit to the Department all the requested documentation by the due date. The Licensee was not able to provide the requested documents to the LPA during today’s visit.

During the tour, LPA observed that Staff 1 (S1) has a criminal record clearance but was not associated to the facility. This poses a potential health & safety risk to the residents in
**********************CONTINUED ON LIC-809C**********************
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
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 3
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
RIVERSIDE, CA 92507

FACILITY NAME: GARDEN VILLE HOME CARE
FACILITY NUMBER: 366427615
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2022
Section Cited

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87755: Inspection Authority of the Licensing Agency - The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand...
This requirement was not met as evidenced by:
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The Licensee failed to submit all the requested documentation by the due date.
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Type B
02/18/2022
Section Cited

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87355: Criminal Record Clearance - A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another...
This requirement was not met as evidenced by:
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Based on interviews and record reviews, Licensee failed to associate S1 to the facility when they started working on 2/4/2022
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
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
RIVERSIDE, CA 92507
FACILITY NAME: GARDEN VILLE HOME CARE
FACILITY NUMBER: 366427615
VISIT DATE: 02/04/2022
NARRATIVE
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care. LPA was informed that S1 started working at the facility on 2/4/2022.

Refer to LIC809D for deficiencies cited. An exit interview was conducted where this report, LIC809D, and appeal rights were discussed with the licensee by phone and a copy was sent to the licensee electronically.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3