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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881669
Report Date: 02/23/2026
Date Signed: 02/23/2026 07:34:11 PM

Document Has Been Signed on 02/23/2026 07:34 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:ABC 1 LLCFACILITY NUMBER:
331881669
ADMINISTRATOR/
DIRECTOR:		PROTHRO, ESTERFACILITY TYPE:
735
ADDRESS:462 WINDFLOWER LANETELEPHONE:
(951) 238-1035
CITY:PERRISSTATE: CAZIP CODE:
92570
CAPACITY: 6CENSUS: 3DATE:
02/23/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Amy Gasaway, AdministratorTIME VISIT/
INSPECTION COMPLETED:
07:40 PM
NARRATIVE
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On 02/23/2026, Licensing Program Analysts (LPAs) Ahliah Sharp and Janira Arreola made an unannounced visit to the facility to conduct a required annual inspection. LPA was greeted and granted entry by Administrator Amy Gasaway who was informed of the purpose of the visit. The facility has a fire clearance for six (6) ambulatory clients only, age range 18 through 59.

Facility is a two story building with five (5) bedrooms, three (3) bathrooms, laundry room, living room, office, dining area, kitchen and attached garage. LPAs observed clients’ bedrooms with the required bedding and furniture, such as; clean mattresses/linen, night stands, dressers, chairs, lighting, and emergency lighting. Client bathrooms had clean appliances that were operating in safe and sanitary condition and the showers contained non-slip surface. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working conditions. Facility met the required two-day supply of perishable and seven day supply of non-perishable foods. Water temperature in the kitchen and bathrooms measured within regulation at 115.3 degrees F.

Client and staff files were locked in the office cabinet. Client medication was centrally stored and locked in the kitchen cabinet. There are no pools or body of water on the premises, and no firearms. All passageways were free from obstruction, except for the back yard, it was blocked and locked but corrected immediately. LPA observed two fire extinguishers in the facility with the last service date of 1/13/2026. The smoke detectors and carbon monoxide alarms were operational. LPA observed the required postings of the emergency disaster plan, resident personal rights, complaint procedures, employee rights, visitation rights, facility sketch, and the See Something Say Something poster.

Continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Ahliah Sharp
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2026
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 6
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)
Page: 2 of 6
Document Has Been Signed on 02/23/2026 07:34 PM - It Cannot Be Edited


Created By: Ahliah Sharp On 02/23/2026 at 06:16 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: ABC 1 LLC
FACILITY NUMBER: 331881669

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)
80019 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:
(2) Obtain a California clearance or a criminal record exemption as required by the Department

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above with one staff that was not fingerprint cleared prior to working at the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2026
Plan of Correction
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Administrator removed uncleared staff at time of the visit. Required to submit required documents prior to staff returning to work at facility.
Section Cited
Deficient Practice Statement
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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.
Jazmond D Harris
NAME OF LICENSING PROGRAM MANAGER:
Ahliah Sharp
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/23/2026 07:34 PM - It Cannot Be Edited


Created By: Ahliah Sharp On 02/23/2026 at 06:26 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: ABC 1 LLC
FACILITY NUMBER: 331881669

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
80087 Buildings and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above with ensuring exits were free from debri and locked gate, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2026
Plan of Correction
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Administrator immediately moved obstruction and removed the lock from the gate.
Type B
Section Cited
CCR
80065(g)(1)
80065 Personnel Requirements
(g) All personnel, including the licensee, administrator and volunteers, shall be in good health, and shall be physically, mentally, and occupationally capable of performing assigned tasks.
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above by one of the staff did not have the necessary health screening,which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/02/2026
Plan of Correction
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Administrator will provide a copy of the health screening via email, in week
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jazmond D Harris
NAME OF LICENSING PROGRAM MANAGER:
Ahliah Sharp
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/23/2026 07:34 PM - It Cannot Be Edited


Created By: Ahliah Sharp On 02/23/2026 at 06:41 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: ABC 1 LLC
FACILITY NUMBER: 331881669

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087.2(b)
85087.2 Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in not ensuring outside area has comfortable furnishings with ample shade available, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/02/2026
Plan of Correction
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Administrator will be purchasing seating and covering and providing proof to LPA via email.
Section Cited
Deficient Practice Statement
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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.
Jazmond D Harris
NAME OF LICENSING PROGRAM MANAGER:
Ahliah Sharp
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
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: ABC 1 LLC
FACILITY NUMBER: 331881669
VISIT DATE: 02/23/2026
NARRATIVE
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(Continued from LIC 809

Facility contains emergency supplies and first aid kits with the required items. The facility has a working telephone that was tested for use by LPA.

LPA observed that the physical plant is clean, in good repair, and otherwise hazard-free during today’s visit. LPA determined the facility has the following deficiencies:

· One (1) staff did not have health clearance

· One (1) staff violated section 80019(e)(2) by failing to have the proper fingerprint clearances (citation was issued)

· Facility failed to have proper seating and covering in the back yard and

· Facility had a lock on the back gate, and what appeared to be a fold-out table was blocking that gate.

An exit interview was conducted, and this report was discussed and provided to Administrator Gasaway.

NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Ahliah Sharp
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026
LIC809 (FAS) - (06/04)
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