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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881265
Report Date: 04/09/2025
Date Signed: 04/09/2025 03:06:36 PM

Document Has Been Signed on 04/09/2025 03:06 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:SRI PARK VIEWFACILITY NUMBER:
331881265
ADMINISTRATOR/
DIRECTOR:		ADAMS, ANDYFACILITY TYPE:
735
ADDRESS:23097 PARK VIEW COURTTELEPHONE:
(818) 635-4820
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 5CENSUS: 2DATE:
04/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Administrator, Andy AdamsTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 04/09/2025, Licensing Program Analyst (LPA) Debbie Palacios made an unannounced visit to conduct the required annual inspection. LPA was greeted at the door by Caregiver Katunge Wambua and explained the purpose of the visit. Administrator Andy Adams arrived shortly after. At the time of the visit, two (2) clients and two (2) caregivers were present at the facility. The facility is approved for five (5) ambulatory clients ages from 18 through 59
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The facility is a one story home with four (4) client bedrooms and one (1) office room, three (3) bathrooms, living room, kitchen, backyard patio, garage and a laundry room. LPA observed clients bedroom furnishings to be in good repair with adequate lighting. Furniture throughout the house was observed to be in good condition. Clients have clean linen in good repair and sufficient hygiene products to meet their needs. All required postings are placed in a prominent area; facility sketch, exit routes, personal rights, and emergency phone numbers were found posted in the facility. Facility's Administrator certificate was noted to be active until 01/15/2026. Facility has multiple operating dual smoke alarms and carbon monoxide detector that meet statutory standards. LPA observed one (1) Fire extinguisher was examined and determined to be in compliance. All inside and outside passageways are clear of obstructions. There are no pools or bodies of water observed.

LPA observed the kitchen area to be clean and odor free; a 2-day supply of perishable, and a 7- day supply of non perishable foods. Medication is locked and stored in the closet near the entrance; facility also keeps their sharp knifes in a container in the closet. Chemicals and poisons are stored in a locked cabinet in the garage. (Continue on LIC809C)
NAME OF LICENSING PROGRAM MANAGER: Tricia Danielson
NAME OF LICENSING PROGRAM ANALYST: Debbie Palacios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2025
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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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: SRI PARK VIEW
FACILITY NUMBER: 331881265
VISIT DATE: 04/09/2025
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Continued from LIC809

LPA observed that the laundry room was locked.

Client files reviewed had updated Individual Program Plans and signed admission agreement. Staff files reviewed had the Department's required training records and valid first aid/CPR certification.

LPA reviewed the Record Of Client's/Resident's Safeguarded Cash Resources (LIC 405) for two (2) clients and LPA did not discover any discrepancies.

During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Andy Adams.

NAME OF LICENSING PROGRAM MANAGER: Tricia Danielson
NAME OF LICENSING PROGRAM ANALYST: Debbie Palacios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC809 (FAS) - (06/04)
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