336403573-9-8-2025-18-AS-SMAZ-DLBT68-20250908142642

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336403573
Report Date: 09/08/2025
Date Signed: 09/08/2025 02:27:32 PM

Document Has Been Signed on 09/08/2025 02:27 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:	VILLAGE, THE		FACILITY NUMBER:	336403573
ADMINISTRATOR/ DIRECTOR:	ROB TAKAMI		FACILITY TYPE:	741
ADDRESS:	2200 WEST ACACIA		TELEPHONE:	(951) 766-5116
CITY:	HEMET	STATE: CA	ZIP CODE:	92545
CAPACITY: 452		CENSUS: 327	DATE:	09/08/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:21 AM
MET WITH:	Bill Fredricksen-Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:30 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), Stephanie Martinez, made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was greeted and allowed to enter the facility to conduct the inspection. On today’s visit the LPA met with Administrator, Bill Fredricksen, and Assisted Living Director, Michelle Flores. They were notified of the purpose for the visit. PHYSICAL PLANT: The Licensee appears to be operating the facility within the conditions and limitations specified on the license. Residents appear to be protected against immediate hazards. Outdoor and indoor passageways are kept free of obstruction. According to Flores, there are no weapons kept on the property. Disinfectants, cleaning solutions, and poisons were inaccessible to unauthorized individuals. A comfortable temperature was being maintained in the building. There was sufficient lighting in resident bedrooms to ensure the comfort and safety of residents. Resident bedrooms had all required furniture in place. The hot water was tested in several resident bedrooms and observed to be within regulatory requirements. Toilets, hand washing and bathing facilities were kept safe, sanitary, and in operating condition. Additional equipment for physically handicapped residents is available. The carbon monoxide alarms were tested and observed to be operable. The fire alarm panel was inspected in the assisted living and independent living buildings and observed to be operating normally. The interior and exterior areas of the facility were observed to be exceptionally clean and well maintained. FOOD SERVICE: There was a variety of food which appeared to be selected and stored in a safe and healthful manner. Food supply of nonperishable and perishable foods was sufficient. Sufficient supplies for resident's dinning use was observed to be available.

NAME OF LICENSING PROGRAM MANAGER: Rikesha Stamps
NAME OF LICENSING PROGRAM ANALYST: Stephanie Martinez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2025

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 3

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 3

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: VILLAGE, THE	FACILITY NUMBER: 336403573
	VISIT DATE: 09/08/2025

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
26
27
28
29
30
31
32

RECORD REVIEW: Staff files had required training; including, but not limited to, Reporting Requirements, and Emergency and Disaster Training. Training on special health conditions was observed on file. Admission Agreements, Medical Assessments (Physician's Reports), Assessments, and Service Plans were observed on file for residents in care. Resident and facility files were observed to be well organized. Administrator Fredricksen has an active Administrator's certificate, which expires on 09/30/2026. The facility currently has 6 residents in care receiving hospice services; which is within their Hospice Waiver limit. Per Fredricksen, the Licensee corporation is active with the California Secretary of State and proof of current Limited Liability Insurance was observed to be in place.

MEDICATION: One of one medication carts was inspected. Medications were labeled and maintained in compliance with label instructions and State and Federal law. Medications were observed to be safe, locked, and inaccessible to residents in care.

No deficiencies have been cited at this time. This report was reviewed with Administrator Fredricksen and AL Director Flores and a copy was provided.

NAME OF LICENSING PROGRAM MANAGER: Rikesha Stamps
NAME OF LICENSING PROGRAM ANALYST: Stephanie Martinez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3