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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881543
Report Date: 08/08/2025
Date Signed: 08/08/2025 03:21:38 PM

Document Has Been Signed on 08/08/2025 03:21 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:UNITED IN CHANGE - AVENIDA HOUSEFACILITY NUMBER:
331881543
ADMINISTRATOR/
DIRECTOR:		MONTGOMERY, MONICAFACILITY TYPE:
735
ADDRESS:26452 AVENIDA DE LA PAZTELEPHONE:
(951) 498-1770
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 4CENSUS: 1DATE:
08/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Licensee, Etta SimpsonTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA met with Licensee, Etta Simpson, who was informed of the purpose of the visit. At the time of the visit there was (2) staff and (1) clients present.

The facility is a two story home with (3) client bedrooms and (2) client bathrooms with laundry room and attached garage. The upstairs is comprised of (1) staff bedroom and (1) staff bathroom.

The facility is approved for (4) ambulatory clients. LPA observed (1) client in care who had a LIC602 noting the client is non ambulatory, however the LIC602 does not have the date, name or signature of the attending physician or the result of the last TB test. LPA conducted client and staff interview, which revealed they are able to evacuate and conduct transfers on their own. Based on incomplete and conflicting information, LPA issued a citation for the client to have a new completed LIC602 on file. The licensee agreed to provide an update LIC602 as a correction and ensure all clients admitted are compatible with the facility fire clearance.

The facility is licensed as an Adult Residential Facility serving adults ages 18-59. LPA reviewed records for client in care which revealed they are over the age of 59. LPA issued a technical advisory note and advised the licensee on Acceptance and Retention Limitations for ARF facilities.

NAME OF LICENSING PROGRAM MANAGER: Carolyn Tuba
NAME OF LICENSING PROGRAM ANALYST: Janira Arreola
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2025
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: UNITED IN CHANGE - AVENIDA HOUSE
FACILITY NUMBER: 331881543
VISIT DATE: 08/08/2025
NARRATIVE
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Infection Control: LPA observed hand hygiene, personal hygiene supplies, PPE equipment, and cleaning supplies to do regular cleaning of the facility. Infection control plan was reviewed and provided.

Physical Plant: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature read 119.8F.

Food Service: LPA observed facility kitchen had the ability to prepare food in a clean environment. LPA observed the facility's food supply which met the requirements.

Care & Supervision/Administration: Staff is present for the supervision of clients during the visit. LPA also reviewed the staff schedule showing staff coverage. The administrator possesses a current administrator's certificate. The current administrator is not listed on the staff schedule and not able to meet LPA during the time of the visit. Staff present for the visit provided records to the LPA, however it was observed some records were incomplete. LPA issued a technical violation advising the Licensee to document the hours the administrator is present at the facility and to audit records for completeness in order to provide records to licensing in a timely manner.

Record Review and Resident/Staff Files: LPA reviewed (4) staff files and training. All staff have criminal clearance and updated CPR/First Aid Certification. (2) staff did not have a copy of their LIC503 Health Screening during the visit. LPA issued a deficiency and created a plan of correction with the licensee during the time of the visit. (1) client file was reviewed, which did not have client personal rights, personal property form, complete medical assessment, and did not have a documented care plan. LPA issued a deficiency and plan of correction with the licensee.
NAME OF LICENSING PROGRAM MANAGER: Carolyn Tuba
NAME OF LICENSING PROGRAM ANALYST: Janira Arreola
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
LIC809 (FAS) - (06/04)
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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: UNITED IN CHANGE - AVENIDA HOUSE
FACILITY NUMBER: 331881543
VISIT DATE: 08/08/2025
NARRATIVE
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Health Related Services/ Incidental Medical Services: All client medication was locked. LPA reviewed client medications and found all medication listed on Medication Administration Records (MAR) and all medications kept in the originally received containers with required labeling.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies and first aid kit with all required items. The last conducted drill was 08/04/2025, technical assistance note was issued for facility to document the staff participating in the drill.

Technical Support Services (TSP) was offered to the licensee who expressed interest in the program. A referral for services will be completed. LPA also provided website information on where the Licensee can access TSP guides. An exit interview was conducted where this report. LIC809-D pages, technical notes, and appeal rights were reviewed and provided.
NAME OF LICENSING PROGRAM MANAGER: Carolyn Tuba
NAME OF LICENSING PROGRAM ANALYST: Janira Arreola
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/08/2025 03:21 PM - It Cannot Be Edited


Created By: Janira Arreola On 08/08/2025 at 02:41 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: UNITED IN CHANGE - AVENIDA HOUSE
FACILITY NUMBER: 331881543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above with (2) staff who did not have a LIC503 on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
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The licensee agreed to have staff complete the LIC503 for the (2) staff and provide proof to the LPA by the POC due date.
Section Cited
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
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.
Carolyn Tuba
NAME OF LICENSING PROGRAM MANAGER:
Janira Arreola
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/08/2025 03:21 PM - It Cannot Be Edited


Created By: Janira Arreola On 08/08/2025 at 02:41 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: UNITED IN CHANGE - AVENIDA HOUSE
FACILITY NUMBER: 331881543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Type B
Section Cited
CCR
80070(b)
(b) Each record must contain information including, but not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in with (1) client who did not have personal rights, personal property form, completed medical assesment, or care plan on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
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The licensee agreed to complete the client file and send copies of the documents to the LPA by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Carolyn Tuba
NAME OF LICENSING PROGRAM MANAGER:
Janira Arreola
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2025


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 08/08/2025 03:21 PM - It Cannot Be Edited


Created By: Janira Arreola On 08/08/2025 at 02:48 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: UNITED IN CHANGE - AVENIDA HOUSE
FACILITY NUMBER: 331881543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(e)
(e) The licensing agency shall have the authority to require the licensee to obtain a current written medical assessment, if such an assessment is necessary to verify the appropriateness of a client's placement.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in with (1) client whose LIC602 was incomplete and provided contradicting information from LPA interview with staff and client and observations of ambulatory status which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
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The licensee agreed to have a completed LIC602 by the client's primary care phsyican reflecting the accurate ambualtory status. LIC602 to be submitted to the LAP by POC due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Carolyn Tuba
NAME OF LICENSING PROGRAM MANAGER:
Janira Arreola
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2025


LIC809 (FAS) - (06/04)
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