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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800057
Report Date: 05/06/2025
Date Signed: 05/06/2025 03:20:45 PM

Document Has Been Signed on 05/06/2025 03:20 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:LARK RESIDENTIAL HOMEFACILITY NUMBER:
331800057
ADMINISTRATOR/
DIRECTOR:		CASTRO, LUDYFACILITY TYPE:
735
ADDRESS:1008 MEADOWVIEW COURTTELEPHONE:
(951) 520-1070
CITY:CORONASTATE: CAZIP CODE:
92880
CAPACITY: 5CENSUS: 3DATE:
05/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Staff Janet ThomasTIME VISIT/
INSPECTION COMPLETED:
03:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Raquel Hernandez made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA was granted entry to the facility by staff Janet Thomas. The facility is a five (five) bedroom, two (2) bathroom home and, with a kitchen/dining area, living room and attached garage. The facility is an Adult Residential Facility (ARF) level 4i designated home vendor by Inland Regional Center. Licensed capacity is (5) current census (3). LPA was accompanied by Staff Janet Thomas to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean.. LPA observed sufficient furniture and lighting throughout the facility. The hot water temperature tested within regulation at 130 degrees F. Deficiency will be issued. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. LPA Hernandez observed fire and earthquake drill was last done in August of 2024. Deficiency will be issued. LPA observed bleach and cleaning disinfectants underneath client's bathroom sink unlocked accessible to clients in care. Deficiency will be issued. Additionally, LPA observed gardening scissors located outside accessible to clients in care. There was a designated space for client/staff files. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Raquel Hernandez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2025
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 8
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: LARK RESIDENTIAL HOME
FACILITY NUMBER: 331800057
VISIT DATE: 05/06/2025
NARRATIVE
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Record Review: LPA reviewed three (3) client files for admission agreements, updated physician report, and needs and services plans. LPA Hernandez observed for Client #1 (C1) and Client #2 (C2) did not have an admission agreement in their personal file. Deficiency will be issued. Additionally, LPA observed for Client #1 (C1) no restricted health care plan located in client file. Deficiency will be issued. LPA reviewed three (3) client medications and verified P&I. LPA observed for Client #1 (C1) AM medication was not documented in Medication Administration Record (MAR). Deficiency will be issued. No issues with P&I were observed. LPA also reviewed two (2) staff files for First Aid/CPR and CPI certification, criminal record clearance, trainings, and health screenings. LPA Hernandez observed Staff #1 (S1), Staff #2 (S2), Staff #4 (S4), Staff #5 (S5), Staff #6 (S6), Staff #7 (S7) to not have an updated CPI certification. Deficiency will be issued. LPA Hernandez observed Staff #1 (S1), Staff #2 (S2), Staff #4 (S4), Staff #6 (S6) to not have an updated CPR certification. Deficiency will be issued.

Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) (LIC809D) was discussed and provided to Staff Janet Thomas.

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Raquel Hernandez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 05/06/2025 03:20 PM - It Cannot Be Edited


Created By: Raquel Hernandez On 05/06/2025 at 02:17 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: LARK RESIDENTIAL HOME
FACILITY NUMBER: 331800057

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not ensuring cleaning solutions such as bleach were locked and kept inacessible to clients in care as well as gardening scissors located outside in backyard, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2025
Plan of Correction
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Licensee stated to submit staff training on storing disinfectants and cleaning solutions to LPA Hernandez by Plan of Correction (POC) due date.
Type A
Section Cited
CCR
80088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (2) Taps delivering water at 125 degrees F (51.6 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not ensuring water temperature tested within regulation and tested at 130 degrees Farenheit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2025
Plan of Correction
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Licensee stated to submit photo documentation of water temperature testing within 105-125 degrees Farenheit to LPA Hernandez by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Raquel Hernandez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 05/06/2025 03:20 PM - It Cannot Be Edited


Created By: Raquel Hernandez On 05/06/2025 at 02:17 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: LARK RESIDENTIAL HOME
FACILITY NUMBER: 331800057

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068(g)
Admission Agreements
(g) The licensee shall retain in the client's file the original of the initial admission agreement and all subsequent modifications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not ensuring Client #1 (C1) and Client #2 (C2) had admission agreement located in personal file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2025
Plan of Correction
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Licensee stated to submit to LPA Hernandez admission agreement for C1 and C2 by Plan of Correction (POC) due date.
Type B
Section Cited
CCR
80092.2(a)
Restricted Health Condition Care Plan
(a) If the licensee of an ARF chooses to care for a client with a restricted health condition, as specified in Section 80092, the licensee shall develop and maintain, as part of the Needs and Services Plan, a written Restricted Health Condition Care Plan. The plan must include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not ensuring Client #1 had a restricted health care plan located in their personal file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2025
Plan of Correction
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Licensee stated to submit to LPA Hernandez a Restricted Health Care Plan for C1 by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Raquel Hernandez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 05/06/2025 03:20 PM - It Cannot Be Edited


Created By: Raquel Hernandez On 05/06/2025 at 02:17 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: LARK RESIDENTIAL HOME
FACILITY NUMBER: 331800057

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80023(d)
Disaster & Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not ensuring earthquake and fire drills were completed and documented as last drill was done August 2024, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2025
Plan of Correction
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Licensee stated to submit to LPA Hernandez earthquake and fire drill for May 2025 by Plan of Correction (POC) due date.
Type B
Section Cited
CCR
85165(b)
Emergency Intervention Staff Training
(b) Staff who use, participate in, approve or provide visual checks of manual restraint or seclusion, shall have a minimum of sixteen hours of emergency intervention training and be certified for having successfully completed the training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not ensuring Staff #1 (S1), Staff #2 (S2), Staff #4 (S4), Staff #5 (S5), Staff #6 (S6), Staff #7 (S7) had an updated CPI certification which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2025
Plan of Correction
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Licensee stated to submit to LPA Hernandez a CPI training date or certification by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Raquel Hernandez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 05/06/2025 03:20 PM - It Cannot Be Edited


Created By: Raquel Hernandez On 05/06/2025 at 02:17 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: LARK RESIDENTIAL HOME
FACILITY NUMBER: 331800057

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85165(f)(7)
Emergency Intervention Staff Training
(f) The administrator who will approve the continued use of a manual restraint or seclusion shall complete additional training which shall include the following: (7) Current first aid certification and current certification in the use of cardiopulmonary resuscitation (CPR).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above by not ensuring Staff #1 (S1), Staff #2 (S2), Staff #4 (S4), Staff #6 (S6) have an updated CPR certification, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2025
Plan of Correction
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2
3
4
Licensee stated to submit to LPA Hernandez a CPR training date or certification by Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Raquel Hernandez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 05/06/2025 03:20 PM - It Cannot Be Edited


Created By: Raquel Hernandez On 05/06/2025 at 02:25 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: LARK RESIDENTIAL HOME
FACILITY NUMBER: 331800057

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above by not ensuring Client #1 (C1) AM medication was documented on Medication Administration Record (MAR) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2025
Plan of Correction
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2
3
4
Licensee stated to submit staff training on MAR documentaion by Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Raquel Hernandez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


LIC809 (FAS) - (06/04)
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