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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403613
Report Date: 10/19/2025
Date Signed: 10/19/2025 01:51:10 PM

Document Has Been Signed on 10/19/2025 01:51 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:JIREH HOUSEFACILITY NUMBER:
336403613
ADMINISTRATOR/
DIRECTOR:		CASSANDRA KNIGHTENFACILITY TYPE:
735
ADDRESS:51935 RIZATELEPHONE:
(951) 849-1985
CITY:CABAZONSTATE: CAZIP CODE:
92230
CAPACITY: 5CENSUS: 3DATE:
10/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:47 AM
MET WITH:Cherron Jackson, House ManagerTIME VISIT/
INSPECTION COMPLETED:
01:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) LaVette Farlow conducted an unannounced required annual inspection to the facility. LPA met with DSP staff Christine Oyler and discussed the purpose of the visit. Christine notified the House Manager, Cherron Jackson of my arrival and LPA needing access to files and documents.

The facility is an Adult Residential Facility (ARF), level 4i. The facility is an Inland Regional Center (IRC) certified vendor with a license capacity of (5) and a current census of (3). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant & Operation: Indoor and outdoor passageways are free of obstruction. The facility has no swimming pools or similar bodies of water. Facility's backyard is enclosed and gated. Indoor and outdoor activity areas are sufficient for clients in care. Client activities include community outings, day program participation, facility parties, board games, and puzzles. The facility has sufficient lighting and is maintained at a comfortable temperature 70 degrees Fahrenheit. Client bathrooms were operating in sanitary conditions. The hot water temperature measured at 129.8, 127.4 and 137.0 degrees F. Which is above regulation. A Deficiency issued. Client bedrooms have sufficient lighting and furniture in good repair. Facility has operating smoke detector and carbon monoxide alarms, laundry equipment and telephone service. LPA observed cleaning supplies in the kitchen cabinet and not secure. A Deficiency issued. The facility has sufficient linen and personal hygiene items for clients in care. The facility has posted in a common area CCLD complaint poster, emergency telephone numbers, weekly menu, disaster evacuation plan, client roster, personnel report, and facility staff schedule.


Food Service: The facility has sufficient non-perishable and perishable food supply for clients in care. Sharps were kept locked inaccessible to clients in care. LPA observed a locked area for chemicals in the garage.
*** Continuation on LIC809C***
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2025
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 10
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: JIREH HOUSE
FACILITY NUMBER: 336403613
VISIT DATE: 10/19/2025
NARRATIVE
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Care & Supervision: Facility has 24 hour care staff. Staff working have criminal record clearances.

Record Review: LPA reviewed two (2) Client files for Admission Report, Medical Assessment/Physician Report, IPP, Needs and Service, and P&I audit. LPA observed that one (1) out of two (2) clients was missing a current Physician Report and Admission Agreement. A Deficiency issued. LPA conduct a audit of three (3) out of three (3) clients financial ledgers. LPA observed that one (1) out of three (3) clients ledger had an discrepancy. LPA found that a receipt was missing and the ledger and available fund did not match the report. A Deficiency issued. LPA reviewed three (3) out of three (3) staff files for Criminal Background Clearance, Health Screening Report/TB Test Results, Training, CPR/First Aid Certificate, and CPI Certificate. LPA observed that staff were missing a Health Screening and TB test results. LPA observed that two (2) out of three (3) staff was missing current training and CPR and CPI certificate. Last fire drill was conducted on 10/2025. LPA reviewed the Facility file for Liability Insurance/Surety Bond, LIC610D Emergency and Disaster Plan, LIC9282 Infection Control Plan, Personnel Report, Fire Drills, CCL poster, Personal Rights, and Criminal Record Clearance. LPA observed that the facility did not review and sign the Emergency and Disaster plan, and Infection Control plan. A Technical violation cited.

Medical Related Services: Client’s medications are labeled and centrally stored in a locked cabinet. LPA conducted an audit of 2 clients medication. LPA observed two (2) out of two (2) clients in care medication and observed no discrepancy were found.

Based on observations and record review, deficiencies and technical violation were cited per Title 22, Division 6 of The California Code of Regulations.

An exit interview was conducted where this report LIC809, LIC809C, LIC809D and appeal rights were discussed and copies of the reports were provided to House Manager Cherron Jackson.
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2025
LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 10/19/2025 01:51 PM - It Cannot Be Edited


Created By: Lavette Farlow On 10/19/2025 at 12:51 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: JIREH HOUSE
FACILITY NUMBER: 336403613

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not ensuring all cleaning supplies or toxic are in a secured and locked cabinet at all times which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2025
Plan of Correction
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Licensee will review with all staff and conduct a training on the importance of securing all cleaning supply and toxic. Licensee agrees to submit a statement of understanding of the above cited regulations and a sign in sheet showing all staff that participated in training by POC due date.
Type B
Section Cited
CCR
80088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (2) Taps delivering water at 125 degrees F (51.6 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 out of 3 areas in the facility by not ensuring that the water temperature measured within regulation. LPA observed the water measured at 129.8, 127.4 and 137.0, with above regulation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2025
Plan of Correction
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Licensee agrees to conduct and test/measure the water temperature three 3x's a day to ensure the temperature is within regulation. Licensee will review the regulation and submit a statement of understanding with a log documenting the measurements by POC due date. If the Licensee can not maintain the measurements within the cited regulation the Licensee agrees to purchase signs stating "caution hot water" and post in designated areas.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2025


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 10/19/2025 01:51 PM - It Cannot Be Edited


Created By: Lavette Farlow On 10/19/2025 at 12:51 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: JIREH HOUSE
FACILITY NUMBER: 336403613

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by not completing the requirements to ensure the licensee or a facility representative had a current Administrator Certificate with two (2) out of two (2) staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2025
Plan of Correction
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Licensee agrees to complete the requirement to complete the Administrator certificate and complete a statement of understanding acknowledging review of regulations by POC due date.
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 3 out of 3 staff file were missing one of the following, TB test results, health screening, CPR/CPI Certificate, and annual training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2025
Plan of Correction
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Licensee agrees to complete and review staff personnel files and ensure all staff have completed and updated all training, health screening, and TB test results, by POC Due date. Licensee agrees to complete a statement of understanding of the above regulation, and proof of completion.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2025


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 10/19/2025 01:51 PM - It Cannot Be Edited


Created By: Lavette Farlow On 10/19/2025 at 12:51 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: JIREH HOUSE
FACILITY NUMBER: 336403613

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and record review, the licensee did not comply with the section cited above in 2 out of 3 staff by not ensuring staff had a current CPR/first aid certificate. LPA observed that the certificate expired 10/16/2025 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2025
Plan of Correction
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Licensee agrees to conduct and complete CPR training for all staff, complete and submit a statement of understanding of the cited regulation and proof of completed training by POC due date.
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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 Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 2 clients in care by not ensuring a admission agree was available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2025
Plan of Correction
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Licensee agrees to review all clients file for required documents and admission agreement. Licensee agrees to update and complete all clients file and review the regulation cited above. Licensee will provide a statement of understanding and submit it to LPA by 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.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2025


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 10/19/2025 01:51 PM - It Cannot Be Edited


Created By: Lavette Farlow On 10/19/2025 at 12:51 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: JIREH HOUSE
FACILITY NUMBER: 336403613

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(b)(14)
Client Records
(b) Each record must contain information including, but not limited to, the following: (14) An account of the client's cash resources, personal property, and valuables entrusted as specified in Section 80026.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 3 clients funds by not ensuring that the financial ledger is free of discrepancies and all receipt are accounted for which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2025
Plan of Correction
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2
3
4
Licensee agrees to complete a regular audit and accurate account of the clients fund and ledgers. Licensee agrees to review and acknowledge the regulation cited above and submit a statement of understanding to LPA by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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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.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2025


LIC809 (FAS) - (06/04)
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