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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530163
Report Date: 08/07/2026
Date Signed: 08/07/2026 05:46:47 PM

Document Has Been Signed on 08/07/2026 05:46 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:COMFORT SENIOR VILLAFACILITY NUMBER:
335530163
ADMINISTRATOR/
DIRECTOR:		AGUINALDO, KRISTENFACILITY TYPE:
740
ADDRESS:3133 SONRISA DRIVETELEPHONE:
(951) 547-4900
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY: 6CENSUS: 6DATE:
08/07/2026
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Staff Member Kristen AguinaldoTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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On August 7, 2026 (08/07/2026), Licensing Program Analyst (LPA) Andrew Martinez arrived at the facility, unannounced, to conduct a Case Management Legal/Non-compliance visit. LPA identified himself and met with staff member Kristen Aguinaldo and gained access to the facility. LPA informed Kristen that the visit is being conducted to follow up on the facility's compliance with the Health & Safety Code Section 1569.38.

Health & Safety Code 1569.38 titled "Posting of licensing reports; disclosure to new residents" requires the licensee to provide a written notice to residents, the resident's responsible party, if any, and the local long-term care ombudsman within 10 days from an occurrence of the department commencing proceedings to suspend or revoke the license of the facility pursuant to Section 1569.50. The notice is described to and shall include the name and contact information for the local long-term care ombudsman and for the Community Care Licensing Division of the department. The notice shall also include the reason given for the commencement of proceedings to suspend or revoke the license of the facility. Also, a written notice and the accusation notice served to the facility shall be posted in a conspicuous location in the facility. The notices shall remain posted until the deficiencies that gave rise to the accusation notice are resolved.

During visit on 08/07/2026, LPA Martinez was unable to locate a copy of the accusation that was served posted in a conspicuous location within the facility. Upon LPA's review of the notice that was provided to residents, the resident's responsible parties, if any, and the local long-term care ombudsman, the notice was observed to not include the reason(s) given for the commencement of proceedings to suspend or revoke the license of the facility. Furthermore, staff member Kristen Aguinaldo revealed to LPA that the notice had not yet been provided to the facility's newest resident, Resident 6 (R6), or the resident's responsible party.
                  *** Continued on LIC 809-C ***
Karen Clemons
Andrew Martinez
DATE: 08/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2026
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: COMFORT SENIOR VILLA
FACILITY NUMBER: 335530163
VISIT DATE: 08/07/2026
NARRATIVE
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In conclusion, during today's visit, LPA Martinez observed and/or staff member Kristen Aguinaldo verbally confirmed the following:
    1.) The accusation notice served by Community Care Licensing Division of the department is not currently posted at Comfort Senior Villa for LPA's immediate inspection/observation.

    2.) The written notice that was provided to the residents, the resident's responsible party, if any, and the local long-term care ombudsman does not include the     reason given for the commencement of proceedings to suspend or revoke the license of the facility pursuant to Section 1569.50 of the Health & Safety Code.

    3.) The written notice to be provided to residents, the resident's responsible party, if any, and the local long-term care ombudsman has not been provided to the facility's newest resident, Resident 6 (R6), that established residency/moved in on 08/07/2026.
Staff member Kristen Aguinaldo was informed that due to failure to comply with sections of Health & Safety Code 1569.38, deficiencies are being issued and civil penalties will be assessed.

Civil penalties will be assessed in the amount of one hundred dollars ($100) for each day of failure to provide notification of correction developed and documented in the Plan of Corrections. The total civil penalty for each day shall not exceed one hundred dollars ($100) regardless of the number of notices that the licensee fails to send that day. The total civil penalty for a continuous violation shall not exceed five thousand dollars ($5,000).

An exit interview was conducted where this Facility Evaluation Report (LIC 809), Deficiencies and Plan of Corrections (LIC 809D), Civil Penalty Assessment (LIC 421FC), and Appeal Rights were discussed with and copies provided to staff member Kristen Aguinaldo.
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Andrew Martinez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/07/2026 05:46 PM - It Cannot Be Edited


Created By: Andrew Martinez On 08/07/2026 at 02:49 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: COMFORT SENIOR VILLA
FACILITY NUMBER: 335530163

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/10/2026
Section Cited
HSC
1569.38(b)

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(b) A licensed residential care facility for the elderly shall provide written notice to a resident, the resident’s responsible party, if any, and the local long-term care ombudsman... of... The department [has] commence[d] proceedings to suspend or revoke the license of the facility pursuant to Section 1569.50.

This requirement is not met as evidenced by:
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Licensee agrees to provide an updated/revised written notice to Resident 6 (R6) and to R6's responsible parties, if any; and completed a signed statement confirming the notice was provided to the resident and the resident's responsible party, if any. The statement and a copy of the updated/revised notice, as proof of completion, is to be submitted via email to LPA by close of business (COB) on Plan of Correction (POC) due date.
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Based on interview, the licensee did not comply with the section cited by ensuring a written notice notifying the facility's newest resident, Resident 6 (R6), of the proceedings to suspend or revoke the facility's license commenced by the department was provided to the residents, the resident's responsible party, if any, and the local long-term care ombudsman at time of admission which poses potential health, safety, and personal rights risks to residents in care.
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Type A
08/10/2026
Section Cited
HSC1569.38(d)

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(d) The notice... provided to a resident and the resident’s responsible party, if any, shall include the reason given for the commencement of proceedings to suspend or revoke the license of the facility... .

This requirement is not met as evidenced by:
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Licensee agrees to revise the notice to include the reason given for the commencement of proceedings to suspend or revoke the license of the facility; to redistribute the notice to all resident's and their responsible parties, if any; and to post the revised notice in the facility. A copy of the revised notice as proof of completion is to be submitted via email to LPA by COB on POC due date.
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Based on observation and record review, the licensee did not comply with the section cited by ensuring the reason given for the commencement of proceedings to suspend or revoke the license of the facility was included within the written notice that was provided to the residents, the resident's responsible party, if any, and the local long-term care ombudsman which poses potential health, safety, and personal rights risks 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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Andrew Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/07/2026 05:46 PM - It Cannot Be Edited


Created By: Andrew Martinez On 08/07/2026 at 04:52 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: COMFORT SENIOR VILLA
FACILITY NUMBER: 335530163

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/10/2026
Section Cited
HSC
1569.38(f)(e)

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(f) The notice required to be posted pursuant to subdivision (e) shall remain posted until the deficiencies that gave rise to the notice are resolved.

This requirement is not met as evidenced by:
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Licensee agrees to post the accusation notice in a conspicuous location within the facility providing photographic proof of its posting and location within the facility; and complete a signed statement of understanding of regulation and assuring Licensing that the notice will remain posted until the deficiencies that give rise to the notice are resolved. The above POC clearance items are to be emailed to LPA by COB on POC due date.
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Based on observation and record review, the licensee did not comply with the section cited by ensuring a copy of the accusation noticed served by Community Care Licensing Division of the department was posted in a conspicuous place in the facility which poses potential health, safety, and personal rights risks 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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Andrew Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2026


LIC809 (FAS) - (06/04)
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