335530186-8-17-2026-56-AS-AMAZ-DX2S8M-20260817133923

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 335530186
Report Date: 08/17/2026
Date Signed: 08/17/2026 01:39:37 PM

Document Has Been Signed on 08/17/2026 01:39 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:	PEPPERMINT RIDGE		FACILITY NUMBER:	335530186
ADMINISTRATOR/ DIRECTOR:	BARRON, STEPHANIE		FACILITY TYPE:	740
ADDRESS:	648 LOCUST ST		TELEPHONE:	(951) 273-7320
CITY:	CORONA	STATE: CA	ZIP CODE:	92879
CAPACITY: 4		CENSUS: 4	DATE:	08/17/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Administrator Stephanie Barron and Facility Manager Claudia Cortes		TIME VISIT/ INSPECTION COMPLETED:	01:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Andrew Martinez made an unannounced visit to the facility for the purpose of conducting the required comprehensive annual inspection. LPA met with Facility Manager Claudia Cortes and was granted entry to the facility. At time of the visit there were (2) staff and (4) residents present. Facility Administrator Stephanie Barron was contacted and informed of the LPA's arrival and administrator arrived shortly after. LPA Martinez explained the purpose of the visit to Administrator Stephanie Barron.

The facility is a (4) bedroom, (2.5) bathroom home with a (2) car attached garage. There is a kitchen, dining/ family area, living room, and staff study. The facility is the Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of (4) non-ambulatory/bedridden residents with delayed egress not permitted. The facility has a hospice waiver for (2) residents, and the current census is (4) residents.

LPA was accompanied by a 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 Division (CCLD). LPA observed no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 73 degrees Fahrenheit (F). LPA inspected resident bedrooms; all equipped with the necessary furniture (e.g., mattresses, lamps, chairs, storage space) and sufficient lightning per regulation. LPA observed that bathrooms were clean, and all bathroom fixtures and equipment were operating appropriately. LPA observed grab bars and non-skid mat in the resident bathrooms. LPA observed sufficient furniture/seating to accommodate indoor and outdoor activities for residents in care and guests. LPA measured taps delivering hot water in the bathroom and kitchen to be at 107 degrees F. The facility is equipped with operating combination smoke alarms and carbon monoxide detectors.

*** Continuation in LIC 809-C ***

Karen Clemons
Andrew Martinez
	DATE: 08/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2026

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: PEPPERMINT RIDGE	FACILITY NUMBER: 335530186
	VISIT DATE: 08/17/2026

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Physical Plant continued: Postings such as personal rights, the CCLD complaint poster, Ombudsman Poster, Labor Laws, facility license, administrator's certificate, and the Emergency Disaster plan were posted in a common area. Sharps were kept locked and inaccessible to residents in care. There is designated storage spaces for residents and staff files, and locked cabinets in the staff study storing residents’ medications.

Food Service: Seven (7) days non-perishable and three (3) days perishable food supply observed at the facility. Food preparation surfaces are kept clean and there is a sufficient amount of tableware (e.g. plates, cups, utensils, etc.) to accommodate residents in care.

Care & Supervision: LPA observed the facility's current Personnel Report LIC 500 and staff schedule shows a sufficient number of staff scheduled to provide twenty-four hour supervision to the residents in care.

Record Review: LPA reviewed (3) completed resident files for admission agreements, updated physician reports, and pre-placement appraisals, as well as their Medications Administration Record (MAR) showing no errors/issues. LPA reviewed three (3) completed staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings with tuberculosis (TB) test results. Disaster/earthquake/fire drills were observed to be conducted quarterly on a shift-rotational basis.

Based on today's observations (1) Technical Violation is being cited based on Title 22 California Code of Regulations.

An exit interview was conducted where this Facility Evaluation Report (LIC 809, LIC 809-C) and Appeal Rights were discussed and copies were provided to Administrator Stephanie Barron.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Andrew Martinez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2026

LIC809 (FAS) - (06/04)

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