335530059-6-1-2026-56-AS-AMAZ-DUN24G-20260601170357

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 335530059
Report Date: 06/01/2026
Date Signed: 06/01/2026 05:04:26 PM

Document Has Been Signed on 06/01/2026 05:04 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	MCF HOME		FACILITY NUMBER:	335530059
ADMINISTRATOR/ DIRECTOR:	APODACA, CHRISTOPHER JOSHU		FACILITY TYPE:	735
ADDRESS:	35775 RHONE LANE		TELEPHONE:	(951) 223-3801
CITY:	WINCHESTER	STATE: CA	ZIP CODE:	92596
CAPACITY: 4		CENSUS: 3	DATE:	06/01/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:15 PM
MET WITH:	Direct Support Professionals (DSP) Kojo Gaisie and Rinny Tapan.		TIME VISIT/ INSPECTION COMPLETED:	05:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Andrew Martinez made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with facility Direct Support Professional (DSP) staff Kojo Gaisie and Rinny Tapan, and discussed the purpose of the visit. LPA conducted a general inspection walk through of facility with DSP Tapan, which included, but was not limited to, the following: Physical Plant: The facility is a single-story (4) client bedroom, (1) staff bedroom, (3) bathroom Adult Residential Facility (ARF) home operating in approved licensed capacity by the Community Care Licensing Division (CCLD), with a current census of (3). The facility has no swimming pools or similar bodies of water. The facility is equipped with sufficient indoor and outdoor space and seating for client activities; all indoor and outdoor passageways were kept free of obstruction. The facility indoor temperature was maintained at 74 degrees Fahrenheit. Cleaning supplies, toxins, and sharps were kept locked and inaccessible to clients in care. The home has two fireplaces that require to be made inaccessible to clients; a Type B deficiency cited. Bedrooms: Client bedrooms were furnished with mattresses, night stands, chairs, storage space, and sufficient lighting. No client bedrooms is a passageway to another bedroom. Bathrooms: Client bathrooms were maintained clean and fixtures were operating properly. Hot water temperatures in the bathrooms was measured at 114 degrees Fahrenheit. Food Service: Kitchen and dining areas were maintained cleaned. Non-perishable and perishable food supply is sufficient for number of clients in care. Facility refrigerators and freezers were maintained in healthful manner.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Andrew Martinez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/01/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2026

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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MCF HOME	FACILITY NUMBER: 335530059
	VISIT DATE: 06/01/2026

NARRATIVE

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Care & Supervision: The facility has care staff coverage, 24 hours a day, 7 days a week. All staff working in the facility have criminal record clearance through the Department.

Medical Services: Medications were labeled and centrally stored and locked in the staff room, inaccessible to clients in care. LPA reviewed client medications and compared it to the facility's Medication Administration Reports (MARs) and Centrally Stored Medication Log. No medication errors observed.

Record Review: LPA reviewed (3) of (3) client files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed three (3) clients file for P&I records. Licensee records appeared to be accurate and in order, no discrepancies found. (1) of (1) client's file is lacking an IPPl and (1) of (1) client's medical assessment were not available for review; 2 Type B deficiencies are being cited. LPA also reviewed (3) staff files for First Aid/CPR certifications, training, employee personnel documentation and health screenings.

Miscellaneous: The facility maintains a sufficient supply of bed linen, towels, emergency supplies and personal hygiene products for clients in care. The facility is equipped with laundry equipment, telephone service, and a centralized fire/carbon monoxide system. Posters such as personal rights, the Community Care Licensing complaint poster, disaster plans, facility license, and client personal rights were posted in a common area. A Register of Facility Clients LIC 9020 was not available to LPA during visit; A Type A deficiency is being cited.

Based on observations and records reviewed, (4) deficiencies (1 Type A and 3 Type B) are being cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where reports (LIC 809, LIC 809-C, and LIC 809-D) were discussed and a copy of the reports and Appeal Rights were provided to DSP Tapan at the conclusion of the visit.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Andrew Martinez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/01/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2026

LIC809 (FAS) - (06/04)

Page: 6 of 6

Document Has Been Signed on 06/01/2026 05:04 PM - It Cannot Be Edited

Created By: Andrew Martinez On 06/01/2026 at 04:36 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: MCF HOME	FACILITY NUMBER: 335530059
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/01/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1565(e)(1)

Other Provisions

(e) A facility shall have all of the following information readily available during an emergency: (1) A roster of individuals served by the facility, with the date of birth for each individual. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not having a completed Register of Facility Clients LIC 9020 posted in the facility readily available for inspection by Licensing which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/02/2026
	Plan of Correction
1 2 3 4	Licensee will complete a Register of Facility Clients LIC 9020 form and provide proof of completed form(s) and posting of the completed forms via email to Licensing by close of business on POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

	Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:

	Andrew Martinez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/01/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2026

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 06/01/2026 05:04 PM - It Cannot Be Edited

Created By: Andrew Martinez On 06/01/2026 at 04:36 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: MCF HOME	FACILITY NUMBER: 335530059
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/01/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(c)

Fixtures, Furniture, Equipment, and Supplies

(c) Fireplaces and open-faced heaters shall be inaccessible to clients to ensure protection of the clients' safety. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 out of 2 fireplaces did not have adequate measures in place to make fireplaces inaccessible to clients which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/05/2026
	Plan of Correction
1 2 3 4	Licensee to obtain locking mechanism(s) or other safety measure to make both fireplaces in the home inaccessible to clients in care. Licensee to provide proof of completion via email to Licensing by close of business on POC due date.

Type B

Section Cited

CCR

80069(b)

Client Medical Assessments

(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 3 client's file was not maintained properly to have the client's medical assessment on file and ready for Licensing inspection which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/05/2026
	Plan of Correction
1 2 3 4	Licensee to obtain updated client's medical assessment to be maintained in client's file. Licensee to provide proof of completed medical assessment for client via email to Licensing by close of business on 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.

	Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:

	Andrew Martinez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/01/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2026

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 06/01/2026 05:04 PM - It Cannot Be Edited

Created By: Andrew Martinez On 06/01/2026 at 04:36 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: MCF HOME	FACILITY NUMBER: 335530059
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/01/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80070(a)

Client Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above ensuring that all client's records maintained at the facility have current Individual Placement Plans (IPP) and updated Needs and Services Plans which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/05/2026
	Plan of Correction
1 2 3 4	Licensee to locate, obtain, complete and/or update the IPPs and Needs and Services Plans for (3) out of (3) clients in care, and to provide proof of the completed documents via email to Licensing by close of business on POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

	Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:

	Andrew Martinez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/01/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2026

LIC809 (FAS) - (06/04)

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