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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366427615
Report Date: 11/22/2021
Date Signed: 11/22/2021 02:11:47 PM

Document Has Been Signed on 11/22/2021 02:11 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:
11/22/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:09 PM
MET WITH:Reymundo YapTIME COMPLETED:
02:14 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Bueno made an unannounced case management visit to the facility for the purpose of obtaining information on the current status of the home. Community Care Licensing (Department) received information indicating the Licensee has failed to make timely rental payments, resulting in a pending eviction. The facility also has a delinquent account with the Department due t non-payment of Annual fees. LPA was greeted by staff Reymundo Yap, who was informed of the purpose of the visit. Licensee, Dulce Redford, was phoned by LPA and staff and licensee stated the they will not be able to present in the facility for today's visit.

On this visit, LPA discussed with staff Yap and telephonically with licensee Redford that resident responsible parties need a written notice of the facility's defaulted rental payments. Staff informed LPA that the licensee had discussed with resident's responsible parties by phone of the facility's payment rental default and that the licensee is waiting for payment from a government rental assistance program. LPA informed staff and licensee that responsible parties will need a written notice as required by applicable California Code of Regulations (CCR) and Health and Safety Code (HSC). This poses an immediate health & safety risk to the residents in care.
During this visit, LPA also discussed with staff Yap and telephonically with licensee Redford of the delinquent licensing fees. LPA informed Yap and Redford that the current balance due to the Department. This poses an potential health & safety risk to the residents in care.

Refer to LIC809D for deficiencies cited. An exit interview was conducted where this report, LIC809D, and appeal rights were discussed and provided to staff Yap.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2021
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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Document Has Been Signed on 11/22/2021 02:11 PM - It Cannot Be Edited


Created By: Anna Bueno On 11/22/2021 at 01:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 11/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/23/2021
Section Cited
CCR
87211(d)(4)

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(d)(4) The licensee shall notify the Department, the State Long-Term Care Ombudsman, all residents, and...their representatives, in writing within 2 business days of any of the following...events, or knowledge..: The licensee receives a written notice of default of payment of rent...
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Licensee shall ensure that a written notice of default of payments of rent shall be given to resident responsible parties no later than the end of POC date of 11/23/2021. Proof of receipt shall be submitted to the Department
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This requirement was not met as evidenced by:
Based on observations and interviews, the licensee has not provided resident responsible parties a written notice of the facility's defaulted rental payments.
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electronically or in person.
Type B
11/26/2021
Section Cited
HSC1569.185(e)

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(e) The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license.
This requirement was not met as evicenced by:
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Licensee shall ensure that the annual fees are paid in full no later than the POC date of 11/26/2021.
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This requirement was not met as evidenced by:
Based on observations and interviews, the licensee has not paid in full the facility's annual licensing fees to date.
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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 Brown
LICENSING EVALUATOR NAME:Anna Bueno
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2021


LIC809 (FAS) - (06/04)
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