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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881273
Report Date: 03/03/2025
Date Signed: 03/03/2025 11:55:13 AM

Document Has Been Signed on 03/03/2025 11:55 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
RIVERSIDE, CA 92507
FACILITY NAME:AVERY GARDEN SENIOR CARE HOME, INC.FACILITY NUMBER:
331881273
ADMINISTRATOR/
DIRECTOR:		THOMAS, LINDAFACILITY TYPE:
740
ADDRESS:26600 IRONWOOD AVE.TELEPHONE:
(818) 515-9279
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 8CENSUS: 5DATE:
03/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:12 AM
MET WITH:ADMINISTRATOR, LINDA THOMASTIME VISIT/
INSPECTION COMPLETED:
12:06 PM
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On March 03, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with Linda Thomas, Administrator. The facility file review was conducted at the Regional Office and additional records were requested and reviewed on site. The facility is licensed for (8) Elderly Adults and is currently operating at a capacity of (6) Elderly Adults (740), with one resident in the hospital currently.

LPA Mixson toured the facility along with the Administrator, Linda Thomas and made observations pertaining to the annual visit. LPA inspected the facility inside and outside there were no obstructions or debris to the indoor or outdoor passageways. Additionally, there were no bodies of water on the premises. The facility is a single-story home located 26600 Ironwood Ave Moreno Valley CA. 92555.

Physical Plant: The facility phone number is (951) 924-3289 and it is operable. LPA Mixson observed the residents’ bedrooms, and each was equipped with required furniture as per Title 22. LPA Mixson inspected facility bathrooms, and the hot water temperature tested within regulations. The bathrooms were clean, and appliances were operating appropriately. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. The fire extinguisher was last serviced on March 2024. LPA Mixson observed required postings such as "If you See Something, Say Something,” the "Personal Rights," and the PUB 475. The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the residents and staff files, and it was locked and inaccessible to residents in care currently at the time of this visit.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2025
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
RIVERSIDE, CA 92507
FACILITY NAME: AVERY GARDEN SENIOR CARE HOME, INC.
FACILITY NUMBER: 331881273
VISIT DATE: 03/03/2025
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Medications: Were locked and inaccessible to residents in care, and there was a sufficient supply of medication for each resident. The overall facility is clean, the furniture is in good condition. The facility Heating system and other appliances were operable currently at the time of this visit. Administrator informed LPA there were safety lights for night throughout the facility.

Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly, and sharp items are locked.

Care & Supervision/Administration: Adequate staff are present for the supervision of residents in care. Floor plans, telephone numbers and personal rights were found posted in the facility. The listed Administrator possesses a current administrator’s certificate with an expiration date of 08/08/2025.

Records Reviewed and Resident/Staff Files: LPA reviewed staff and residents files, the facility's staff schedule, and previous Community Care Licensing forms. The files reviewed currently have required forms per Regulations. Files reviewed possessed required paperwork.


Disaster preparedness: LPA Mixson reviewed the facility's emergency and disaster plan as well as disaster training binder. LPA observed the last fire drill met the department standards, and continuous training's were conducted and logged per Title 22 regulations.

Infection Control: LPA Mixson observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies for regular cleaning of the facility. LPA reviewed the facility's posted infection control plan and found all required infection control measures, along with the facility plan of operations required sections reviewed.



There were no TA deficiencies observed or cited per Title 22, Division 6 of the California Code of Regulations at this time.
An exit interview was conducted where a copy of this report was discussed and given to Linda Thomas, Administrator.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2025
LIC809 (FAS) - (06/04)
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