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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880846
Report Date: 01/30/2025
Date Signed: 01/30/2025 04:43:55 PM

Document Has Been Signed on 01/30/2025 04:43 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SPRING MEADOWS ASSISTED LIVINGFACILITY NUMBER:
331880846
ADMINISTRATOR/
DIRECTOR:
GARCIA, CYNTHIAFACILITY TYPE:
740
ADDRESS:1601 HEARTLAND WAYTELEPHONE:
(949) 423-8127
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
01/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:22 PM
MET WITH:Licensee/Administrator - Cynthia GarciaTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Licensee/Administrator - Cynthia Garcia and was granted entry to the facility. Licensed capacity is (6) current census (5). LPA was accompanied by Licensee/Administrator Cynthia Garcia 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). LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. 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. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated space for resident/staff files.

During facility tour, LPA observed furniture on patio side, blocking facility pathway. In addition the facility had converted the garage storage into a staff bedroom without building permits. Facility's fire clearance indicated the garage should remain for storage purposes. The facility has residents personal belongs unorganized inside the garage.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a variety of food available for residents. 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.
Efren MalagonTELEPHONE: (951) 248-0337
Mary RicoTELEPHONE: (951) 248-0293
DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2025
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 6
Document Has Been Signed on 01/30/2025 04:43 PM - It Cannot Be Edited


Created By: Mary Rico On 01/30/2025 at 03:33 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: SPRING MEADOWS ASSISTED LIVING

FACILITY NUMBER: 331880846

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 01/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 having bed frames on side patio and garage full with resident clothes unable to walk through which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2025
Plan of Correction
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Licensee stated they will remove the items from the side patio, and organized garage for a clear pathway. In addittion, will send proof to LPA Rico.
Type A
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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Based on observation, the licensee did not comply with the section cited aboved by converting garage storage room into staff bedroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2025
Plan of Correction
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Licensee stated they will convert staff bedroom back to storage and will send proof to LPA Rico.
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:Efren Malagon
TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME:Mary Rico
TELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2025


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 01/30/2025 04:43 PM - It Cannot Be Edited


Created By: Mary Rico On 01/30/2025 at 03:33 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: SPRING MEADOWS ASSISTED LIVING

FACILITY NUMBER: 331880846

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 01/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by not documenting 5 out of the 5 residents PRN which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Licensee stated they will create a PRN sheet that will include the date/time and resident response. In addittion, will send proof to LPA Rico
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Efren Malagon
TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME:Mary Rico
TELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 01/30/2025 04:43 PM - It Cannot Be Edited


Created By: Mary Rico On 01/30/2025 at 03:33 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: SPRING MEADOWS ASSISTED LIVING

FACILITY NUMBER: 331880846

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 01/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by not conducting fire drills which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2025
Plan of Correction
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Licensee stated they will conduct an emergency drill during all shifts, and will provided proof to LPA Rico.
Type B
Section Cited
HSC
1569.695(e)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency:

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 having emergency items ready which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2025
Plan of Correction
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Licensee stated they will have bin ready with all emergency items and will send proof to LPA Rico.
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:Efren Malagon
TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME:Mary Rico
TELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 01/30/2025 04:43 PM - It Cannot Be Edited


Created By: Mary Rico On 01/30/2025 at 03:50 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: SPRING MEADOWS ASSISTED LIVING

FACILITY NUMBER: 331880846

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 01/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)

87355 Criminal Record Clearance(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working..(1) Obtain a Califorina clearance..
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by having S1 working without a criminal record clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2025
Plan of Correction
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Licensee will send proof to LPA they have read/understood the regulation cited above. Licensee stated they will not have S1 working until fingerprint clearance has been granted.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Efren Malagon
TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME:Mary Rico
TELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SPRING MEADOWS ASSISTED LIVING
FACILITY NUMBER: 331880846
VISIT DATE: 01/30/2025
NARRATIVE
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Record Review: LPA reviewed (5) resident files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed (5) resident medications and (2) hospice files. LPA also reviewed (2) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

During medication audit, LPA observed the facility has not been documenting resident's PRN, which include date/time and resident response. In addition, the administrator stated S1 had been working without a criminal record clearance.

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 LIC421BG) was discussed and provided to Licensee/Administrator Cynthia Garcia. Along with Appeal Rights.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC809 (FAS) - (06/04)
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