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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880763
Report Date: 08/07/2026
Date Signed: 08/07/2026 02:53:42 PM

Document Has Been Signed on 08/07/2026 02:53 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:NEW HOPE RESIDENTIAL ELDER CARE IIIFACILITY NUMBER:
331880763
ADMINISTRATOR/
DIRECTOR:		MIKENAS, ANNIE JANE ZFACILITY TYPE:
740
ADDRESS:36040 PEPPERDINE COURTTELEPHONE:
(951) 599-4585
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY: 6CENSUS: 6DATE:
08/07/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Caregiver, Ralp AbanoTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) E. Conchas made an unannounced visit to the facility. The purpose of the visit was to conduct the required comprehensive annual inspection LPA met with a staff member and was granted entry to the facility. Caregiver Ralp Abano assisted LPA in the tour during the visit. At the time of the visit there were three (3) staff present.

The facility is a six (6) bedroom, two & half (2 & 1/2) bathroom home with a kitchen/dining area, living room/activity room. The facility is licensed for a capacity of six (6) bedridden residents. The facility is approved for six (6) hospice waivers. The current census is six (6) residents. LPA was accompanied by Ralp to conduct a general overall inspection.

The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. LPA inspected resident bedrooms which are equipped with required furniture. Bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathrooms to be between 109-115 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. One Fire extinguisher was observed at the facility and was current. Posters such as personal rights, the CCLD complaint poster, labor laws, and the disaster plan were posted in a common area.

LPA observed non-perishable and perishable food supply that was sufficient for the number of residents in care.

LPA observed sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated locked storage space for residents, staff, facility files, first aid kit and medication.

Continue to LIC809-C

Karen Clemons
Edith Conchas
DATE: 08/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2026
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 19
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: NEW HOPE RESIDENTIAL ELDER CARE III
FACILITY NUMBER: 331880763
VISIT DATE: 08/07/2026
NARRATIVE
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LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. Medications/Medication Administration Record (MAR) were audited and observed to be administered appropriately.

LPA reviewed staff files for First Aid/CPR certification, criminal record clearance and health screenings with Tuberculosis (TB) test result.

LPA reviewed facility file for Emergency Disaster plan, Infection Control plan, quarterly drills and liability coverage.

The following was observed and cited:

  • Infection control plan was last reviewed on 04/01/2025.
  • Liability insurance was expired as of 4/24/2026.
  • Room 5 an additional bed with mattress unoccupied. Room 5 does not have a clearance to house 2 clients. Staff 1 stated licensee is working on getting clearance to house an additional resident.
  • Staff room had 3 twin beds.
  • R1, R2, & R3 a pre-appraisal was not in file.
  • 3 staff were present. No designated representative was available.
  • Staff 2 to not have Health screening report completed along with TB results.
  • First aid manual was missing.
  • Resident 1,2, & 3 Emergency contact sheet was incomplete.
  • R1, R2, & R3 had a missing pre-appraisal completed.
  • R1 did not have a complete Physician report. TB results were missing.
  • Inventory property list for R1, R2, & R3 was not observed.
  • Telecommunications form was not completed for all R1, R2 & R3.
  • Quarterly drill was not conducted. The most recent was on May 3, 2026.
  • Emergency disaster plan was last updated on 6/1/2025.
  • Complaint Poster (PUB 475) is posted shall be 20” x 26” in size and be posted in the main entryway of the facility.

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 a copy of this report along with an Appeal Rights were discussed and provided to caregiver Ralp Abano.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Edith Conchas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026
LIC809 (FAS) - (06/04)
Page: 18 of 19
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)
Page: 2 of 19
Document Has Been Signed on 08/07/2026 02:53 PM - It Cannot Be Edited


Created By: Edith Conchas On 08/07/2026 at 01:30 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: NEW HOPE RESIDENTIAL ELDER CARE III
FACILITY NUMBER: 331880763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)(1)(D)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (D) The licensee shall review the use of infection control procedures in the facility at least annually, if local government public health determines an epidemic outbreak has occurred, or if the review is requested by the local licensing agency.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Edith Conchas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2026


LIC809 (FAS) - (06/04)
Page: 9 of 19
Document Has Been Signed on 08/07/2026 02:53 PM - It Cannot Be Edited


Created By: Edith Conchas On 08/07/2026 at 01:13 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: NEW HOPE RESIDENTIAL ELDER CARE III
FACILITY NUMBER: 331880763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)(1)(D)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (D) The licensee shall review the use of infection control procedures in the facility at least annually, if local government public health determines an epidemic outbreak has occurred, or if the review is requested by the local licensing agency.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2026
Plan of Correction
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Per caregiver,the license will update the plan and submit proof to LPA by POC date via email.
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, record review, the licensee did not comply with the section cited above by not having a current insurance update or available which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2026
Plan of Correction
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2
3
4
Per caregiver,the license will update/ renew and submit proof to LPA by POC date via email .
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Edith Conchas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2026


LIC809 (FAS) - (06/04)
Page: 3 of 19
Document Has Been Signed on 08/07/2026 02:53 PM - It Cannot Be Edited


Created By: Edith Conchas On 08/07/2026 at 01:13 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: NEW HOPE RESIDENTIAL ELDER CARE III
FACILITY NUMBER: 331880763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
(a) Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on observation record review, the licensee did not comply with the section cited above by having an additional bed in room 5 prior to fire clearance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2026
Plan of Correction
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2
3
4
Per caregiver, the license will update/ renew and submit picture proof to LPA by POC date via email .
Type B
Section Cited
CCR
87307(a)
Personal Accommodations and Services
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation interview record review, the licensee did not comply with the section cited above by having 3 twin staff bed in staff room which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2026
Plan of Correction
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2
3
4
Per caregiver, the license will remove the beds in staff room submit proof to LPA by POC date via email .
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Edith Conchas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2026


LIC809 (FAS) - (06/04)
Page: 4 of 19
Document Has Been Signed on 08/07/2026 02:53 PM - It Cannot Be Edited


Created By: Edith Conchas On 08/07/2026 at 01:30 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: NEW HOPE RESIDENTIAL ELDER CARE III
FACILITY NUMBER: 331880763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

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 having staff 2have completed TB negative results in file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2026
Plan of Correction
1
2
3
4
Per caregiver,the license will not allow staff 2 to work and have S2 complete TB test and submit results proof to LPA by POC date via email .

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Edith Conchas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2026


LIC809 (FAS) - (06/04)
Page: 8 of 19
Document Has Been Signed on 08/07/2026 02:53 PM - It Cannot Be Edited


Created By: Edith Conchas On 08/07/2026 at 01:30 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: NEW HOPE RESIDENTIAL ELDER CARE III
FACILITY NUMBER: 331880763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(8)(A)
Incidental Medical and Dental Care Services
(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation record review, the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2026
Plan of Correction
1
2
3
4
Per caregiver,the license will purchase a manual and submit picture proof to LPA by POC date via email .
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, record review, the licensee did not comply with the section cited above by not having the plan completed or updated which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2026
Plan of Correction
1
2
3
4
Per caregiver,the license will update and send a copy to LPA by POC date via email .
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Edith Conchas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2026


LIC809 (FAS) - (06/04)
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