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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880614
Report Date: 06/23/2025
Date Signed: 06/23/2025 01:44:40 PM

Document Has Been Signed on 06/23/2025 01:44 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:LEWIS BAILEY SENIOR HOME CAREFACILITY NUMBER:
331880614
ADMINISTRATOR/
DIRECTOR:		LEWIS, TARIFACILITY TYPE:
740
ADDRESS:26364 MALLORY CTTELEPHONE:
(951) 430-1921
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY: 6CENSUS: 2DATE:
06/23/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:37 AM
MET WITH:Tari Lewis, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:04 PM
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Regional Manager (RM) Reyna Lacey conducted an onsite visit and met with Tari Lewis, Administrator and Licensee. During the visit, it was discovered the facility is retaining two residents who are bedridden.

Physician reports, hospice care plans and interviews were conducted. Facility staff confirmed both residents are assisted with repositioning. Hospice care plan for Resident 1 (R1) indicates R1 is bedbound. Pre-placement Appraisal dated 04/29/25 for R1 indicates bedridden.

Hospice care plan for R2 indicates bedbound. Physician Report dated 12/07/2023 indicates R2 is bedridden.

This facility does not have an approved fire clearance to accept or retain bedridden residents.

A deficiency was cited and a civil penalty was assessed in the amount of $500. An exit interview was conducted with Nikita Leiws where this report, the LIC809D, and LIC421 civil penalty assessment form was reviewed. Appeal Rights were reviewed and provided.

Due to technical issues, the report and forms will be emailed to the licensee/administrator.
NAME OF LICENSING PROGRAM MANAGER: Icela Estrada
NAME OF LICENSING PROGRAM ANALYST: Reyna Lacey
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2025
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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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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Document Has Been Signed on 06/23/2025 01:44 PM - It Cannot Be Edited


Created By: Reyna Lacey On 06/23/2025 at 12:17 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: LEWIS BAILEY SENIOR HOME CARE
FACILITY NUMBER: 331880614

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/24/2025
Section Cited
CCR
87202(a)(2)

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Fire Safety (a) All facilities shall maintain a fire clearance approved by city or county fire department ... Prior to accepting/retaining ... the licensee shall notify the licensing agency & obtain an appropriate fire clearance...(2) Bedridden persons. This requirement was not met as evidenced by:
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Licensee stated they will eviction notices to both R1 and R2 by the POC due date. In addition, licensee has submitted an LIC 200 requesting a bedridden fire clearance.
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Based on document review and interview, R1 and R2 are bedridden and need assistance repositioning and this facility does not have a fire clearance for bedridden. This poses an immediate H&S risk to the residents in care.
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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.
Icela Estrada
NAME OF LICENSING PROGRAM MANAGER:
Reyna Lacey
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2025


LIC809 (FAS) - (06/04)
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