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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881036
Report Date: 12/19/2025
Date Signed: 12/19/2025 10:17:52 AM

Document Has Been Signed on 12/19/2025 10:17 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:A HOME 4 WAYNE, INC. 2FACILITY NUMBER:
331881036
ADMINISTRATOR/
DIRECTOR:		WATSON, PAMELAFACILITY TYPE:
735
ADDRESS:1591 ATLAS PEAK LN.TELEPHONE:
(951) 350-0331
CITY:SAN JACINTOSTATE: CAZIP CODE:
92582
CAPACITY: 4CENSUS: 2DATE:
12/19/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:49 AM
MET WITH:ASSISTANT ADMINISTRATOR, MR. WATSONTIME VISIT/
INSPECTION COMPLETED:
10:23 AM
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On December 19, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to the facility to conduct a Health and Safety, case management visit, and met with the Assistant Administrator, Patrick Watson. The LPA made introductions and stated the purpose of the visit.

The Regional Office (RO), received the Fire Safety Inspection Request on 12/16/2025, indicating that the facility Fire clearance was granted. By the Riverside County Fire Department.

The Administrator informed the LPA that currently two residents reside at this facility, with a capacity of four. There were two staff on duty during the time of the visit. During today’s visit, the LPA toured the facility along with the Assistant Administrator and made observations pertaining to the facilities request to include non-ambulatory residents along with the ambulatory residents.

LPA observed the facility utilities to be operating without issues; the medications were locked and inaccessible to the residents in care. The food supply met the regulation requirements. The staff and resident files were found to have the required items per regulations. The facility is two stories, with seven bedrooms and three bathrooms. The residents will utilize four bedrooms and two bathrooms.

The bedrooms were furnished with required items as per regulations at the time of this visit. The facility has adequate linens, towels and a sufficient amount of hygiene products for the residents in care currently. The water temperature was tested and logged, along with fire drills. The smoke and carbon monoxide alarms were observed and are operable. Fire extinguishers are present in the facility and fully charged, and in the green.

The hallways were equipped with night lights. The kitchen was observed to have dishes, silverware, pots, and pans. The knives/sharp items are inaccessible to the residents in care. The staff and resident files, along with the medication were found to have no observable issues at the present time. There is no immediate concern for residents in care.

No deficiencies were observed or cited and per California Health & Safety Code and Code of Regulations, Title 22, Division 6.

An exit interview was conducted, and a copy of this report was explained and provided to the Assistant Administrator, Mr. Watson.

NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Venus Mixson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2025
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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