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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881004
Report Date: 02/26/2026
Date Signed: 02/26/2026 03:50:03 PM

Document Has Been Signed on 02/26/2026 03:50 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:MIDTOWN VILLAFACILITY NUMBER:
331881004
ADMINISTRATOR/
DIRECTOR:		ROMEO LABASTIDAFACILITY TYPE:
740
ADDRESS:2789 RAFFERTY RD.TELEPHONE:
(951) 763-8946
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY: 102CENSUS: 25DATE:
02/26/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Administrator, Romeo Labastida TIME VISIT/
INSPECTION COMPLETED:
03:58 PM
NARRATIVE
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Licensing Program Analyst (LPA), Jarred Torres, and LPA, Robert Campbell, conducted an unannounced annual inspection. Upon entry, The LPAs introduced themselves and explained the purpose for the visit. The LPAs met with Administrator, Romeo Labastida.

The facility is a two-story home with 102 bedrooms for residents. The facility is currently operating at a census of 25 residents. There are no known firearms on the premises. There is no pool and there are no bodies of water on the premises.

The LPAs observed hygiene and cleaning supplies in the facility, which were locked and kept separate from food supplies. The facility has an approved infection control plan on file.

During the tour, the LPAs smelled a gas leak, which was confirmed by the Administrator and SoCal Gas Company, whom showed up in person to assess the leak. Although the bedrooms had furniture in good repair, the LPAs observed rust in a resident's shower, broken blinds in four resident bedrooms, and a rusted fence around the perimeter of the facility which was locked from the inside. A deficiency will be issued for these issues. Please refer to the LIC 809-D. The outdoor area had no tripping hazards. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked and inaccessible to residents. The carbon monoxide detectors were operational, and the hot water temperature was measured at 110°F. The fire extinguishers were observed to be in good condition with the last service being completed on 8/19/2025.

Continued on LIC 809-C...
NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Jarred Torres
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2026
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 5
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MIDTOWN VILLA
FACILITY NUMBER: 331881004
VISIT DATE: 02/26/2026
NARRATIVE
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The LPAs observed the kitchen to have the required two day supply of perishable foods and a seven day supply of non-perishable foods on the premises. There was food debris on the floor, white crusty residue on the ice machine, and a black and brown substance coating the vent above the kitchen range. These issues were discussed with the Administrator, and a deficiency will be issued.

The LPAs observed that adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate.

The LPAs reviewed files for five staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Five resident files were reviewed and contained all required documentation.

The LPAs observed that the centrally stored medication supply was securely locked and inaccessible to clients in care. Medications for five residents were reviewed and the LPAs confirmed that all medications were listed on the Medication Administration Record and accounted for.

The LPAs reviewed the facility’s approved emergency and disaster plan, including documentation that the next fire drill is scheduled for March 5, 2026. All facility exits were clear of obstructions.

Two deficiencies were cited and an exit interview was conducted. A copy of this report was discussed and provided to the Administrator, Romeo Labastida, whose signature on this form confirms receipt of this report.
NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Jarred Torres
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/26/2026 03:50 PM - It Cannot Be Edited


Created By: Jarred Torres On 02/26/2026 at 03:04 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: MIDTOWN VILLA
FACILITY NUMBER: 331881004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2026

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 and interviews, the licensee did not comply with the section cited above due to an ongoing gas leak at the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2026
Plan of Correction
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Administrator, Romeo Labastida, called SoCal Gas Company in the presence of the LPAs. The SoCal Gas employee told Romeo that the gas leak will be fixed on 2/26/2026. The Administrator will provide photographic proof of the fixed gas fixture and work orders to the LPAs e-mail by the POC due date.
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.
Jazmond D Harris
NAME OF LICENSING PROGRAM MANAGER:
Jarred Torres
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/26/2026 03:50 PM - It Cannot Be Edited


Created By: Jarred Torres On 02/26/2026 at 03:04 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: MIDTOWN VILLA
FACILITY NUMBER: 331881004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

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 in 1 out of 1 observed kitchens where food debris was observed on the floor, an ice machine with a crusty white substance was observed, and a brown and black substance coated the kitchen range, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2026
Plan of Correction
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Administrator, Romeo Labastida, will ensure kitchen staff are properly trained on maintaining a sanitary cooking area, and will submit photographic proof of the clean kitchen and completed training via e-mail to CCLD by the POC due date.
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.
Jazmond D Harris
NAME OF LICENSING PROGRAM MANAGER:
Jarred Torres
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2026


LIC809 (FAS) - (06/04)
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