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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530063
Report Date: 03/12/2025
Date Signed: 03/12/2025 11:54:11 AM

Document Has Been Signed on 03/12/2025 11:54 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SIERRA PINES GUEST HOMEFACILITY NUMBER:
335530063
ADMINISTRATOR/
DIRECTOR:		HAMED, HANANFACILITY TYPE:
740
ADDRESS:5051 LA SIERRA AVETELEPHONE:
(786) 219-6008
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY: 25CENSUS: 23DATE:
03/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Administrator Hanan HamedTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 03/12/2025 at 09:05 AM, Licensing Program Analyst (LPA) Beena Singh made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Singh met with Administrator Hanan Hamed and was granted entry to the facility. At the time of the visit there were three (3) staff present, and twenty-three (23) residents present.

The facility is a fourteen (14) bedroom, four (4) bathroom home with a kitchen/dining area, living room/activity room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of twenty-five (25) non-ambulatory residents and approved for six (6) hospice waiver. The current census is twenty-three (23) residents. LPA Singh was accompanied by Administrator Hanan Hamed to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 73 degrees Fahrenheit. LPA Singh inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands and wall lamps, storage space, and sufficient lighting; bathrooms were remodelled and clean, and appliances were operating appropriately. LPA Singh observed sufficient furniture and lighting throughout the facility. LPA Singh measured and observed the water temperatures in the bathroom to be at 110 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguishers were also observed at the facility. Posters such as personal rights, the CCL complaint poster, Ombudsman poster, labor laws, and the disaster plan were posted in a common area.

***Continuation in LIC809C **

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
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
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: SIERRA PINES GUEST HOME
FACILITY NUMBER: 335530063
VISIT DATE: 03/12/2025
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During the tour of the facility, LPA Singh observed cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine Cabinet for the residents with the resident’s medications locked. LPA Singh observed the complete first aid kit and first aid book at the facility.

Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care.

Care & Supervision: The facility has an Administrator present in the facility with appropriate and enough hours to appropriately manage the facility. The facility has sufficient number of staff to provide care and supervision to the residents in care.

Record Review: LPA Singh reviewed four (4) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA Singh observed resident files reviewed were complete. LPA Singh reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, Dementia and other trainings, and health screenings. Last Fire drill completed on 01/8/2025. Medications/Medication Administration Record (MAR) for Resident#and P&I for R#1 and R#4 were audited, and LPA Singh observed no issue.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809),LIC 809C were discussed and provided to Administrator Hanan Hamed

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
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
LIC809 (FAS) - (06/04)
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