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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366427615
Report Date: 03/03/2022
Date Signed: 03/03/2022 12:09:04 PM


Document Has Been Signed on 03/03/2022 12:09 PM - 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
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:
03/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:47 AM
MET WITH:Administrator Dulce RedfordTIME COMPLETED:
12:09 PM
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Licensing Program Analyst (LPA) Anna Bueno arrived at the facility and met with Administrator Dulce Redford for the purpose of obtaining signature for an amended Case Management Report and delivering a POC letter from 2/4/2022.

Signature was obtained and a copy of the amended report and a copy of this report was provided Administrator Dulce Redford.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2022
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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