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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881342
Report Date: 07/30/2025
Date Signed: 07/30/2025 11:04:00 AM

Document Has Been Signed on 07/30/2025 11:04 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:NOVASIR CARE SERVICESFACILITY NUMBER:
331881342
ADMINISTRATOR/
DIRECTOR:		DAVIS, CHRISFACILITY TYPE:
735
ADDRESS:27565 BLOOMING VISTA WAYTELEPHONE:
(310) 462-4240
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY: 4CENSUS: 3DATE:
07/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator, Chris DavisTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
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On 7/30/2025, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced 1-year required visit. LPA Flores met with Administrator, Chris Davis, whom granted entry to the facility. A facility tour was conducted alongside Chris. During the visit, there was no clients present during the visit; all clients were attending day program.

The physical plant consisted of (4) four client bedrooms and (2) two bathrooms, living room, formal dining room, garage, and kitchen. Clients bedrooms were equipped with the required bedding, furniture, and functional lighting. Additional linen and towels are available for clients and appear to be in good repair. LPA did not observe no pools or bodies of water. The facility met the (2) two-day supply of perishable food and (7) seven-day supply of non-perishable items. Dishes were sufficient in supply and in good repair. LPA observed knives and other sharp instruments locked in a cabinet located in the kitchen. LPA observed emergency food and water located in the garage. LPA observed a large cabinet that stored board games and craft material to encourage client activities. Per Administrator, Chris Davis, there are no firearms or ammunition on the premises.

Indoor/outdoor passageways were free of obstructions. LPA observed a fully charged fire extinguisher mounted near the kitchen. Smoke alarms and carbon monoxide detectors were deem fully operable. Water temperature measured at 114.8-degree Fahrenheit meeting within the department's requirements.

(Continue to LIC809C...)
NAME OF LICENSING PROGRAM MANAGER: Rikesha Stamps
NAME OF LICENSING PROGRAM ANALYST: Valerie Flores
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2025
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: NOVASIR CARE SERVICES
FACILITY NUMBER: 331881342
VISIT DATE: 07/30/2025
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(Continuation from LIC809)

Emergency disaster plan, facility sketch, See Something Say Something, Facility License, and Employee Rights Posters were posted on a wall in the living room. Facility staff records review include but are not limited to criminal record clearance, DSP Training, health screenings, valid CPI certification, and First-aid/CPR training. Client records included but not limited to physician reports, weight charts, appraisals, current IPP, dental records, and plan safeguard cash records. No deficiencies were cited during today's visit.

An exit interview was conducted where a copy of this report was provided to Administrator, Chris Davis.
NAME OF LICENSING PROGRAM MANAGER: Rikesha Stamps
NAME OF LICENSING PROGRAM ANALYST: Valerie Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
LIC809 (FAS) - (06/04)
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