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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881420
Report Date: 03/12/2025
Date Signed: 03/12/2025 10:55:27 AM

Document Has Been Signed on 03/12/2025 10:55 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:PENDA HOMES ASSISTED LIVINGFACILITY NUMBER:
331881420
ADMINISTRATOR/
DIRECTOR:		KIMINYEI, MILDREDFACILITY TYPE:
740
ADDRESS:26042 WESTRIDGE AVENUETELEPHONE:
(619) 483-6656
CITY:MENIFEESTATE: CAZIP CODE:
92586
CAPACITY: 6CENSUS: 4DATE:
03/12/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:13 AM
MET WITH:Yasmin Brown, CaregiverTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado conducted a Case Management visit while at the facility for another matter. LPA requested LIC500, Resident roster and resident file. Staff was unable to provide LPA with requested documents. LPA conducted a Health and Safety check. There is no immediate concerns at this time.

There is one (1) deficiency that is being cited per California Health & Safety Code and Code of Regulations, Title 22, Division 6.

An exit interview was conducted with Yasmin Brown, a a copy of this report, LIC 809D, Appeal Rights was provided to Yasmin Brown.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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 2
Document Has Been Signed on 03/12/2025 10:55 AM - It Cannot Be Edited


Created By: Yolanda Delgado On 03/12/2025 at 10:36 AM
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: PENDA HOMES ASSISTED LIVING
FACILITY NUMBER: 331881420

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/18/2025
Section Cited
CCR
87506(a)

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RESIDENT RECORDS:
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not being met as
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Licensee will email all copies of R1's file, LIC500 and Resident roster to LPA by POC due date.
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evidenced by: During the visit, LPA requested to review R1's file, a copy of the LIC500 and Resident roster. Staff could not provide the requested documents during the time of the visit. This poses an immediate health and safety risk to residents in care.
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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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025


LIC809 (FAS) - (06/04)
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