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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403613
Report Date: 07/03/2026
Date Signed: 07/03/2026 01:59:51 PM

Document Has Been Signed on 07/03/2026 01:59 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:
07/03/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Direct Support Staff Christine OylerTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced required annual inspection to the facility. LPA met with House Manager Cherron Jackson and discussed the purpose of the visit.

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, and board games. The facility has sufficient lighting and is maintained at a comfortable temperature. Client bathrooms were operating in sanitary conditions. The hot water temperature measured at 109 and 110 degrees F. Client bedrooms have sufficient lighting and furniture, C2 has a closet door in disrepair; deficiency issued. Facility has operating smoke detector and carbon monoxide alarms, laundry equipment and telephone service. The facility has sufficient linens and personal hygiene items for clients in care. The facility has posted in a common area CCLD complaint poster, weekly menu,Administrator certificate, rights of individuals with developmental disabilities, facility sketch, personnel report, and facility staff schedule.



Food Service: The facility has sufficient non-perishable and perishable food supply for clients in care. Sharps and chemicals were kept locked inaccessible to clients in care.
**** Continuation on LIC 809 – C****
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Sarina Ramirez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2026
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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Document Has Been Signed on 07/03/2026 01:59 PM - It Cannot Be Edited


Created By: Sarina Ramirez On 07/03/2026 at 12:12 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: 07/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80025(b)
Bonding
(b) All licensees, other than governmental entities, who are entrusted to care for and control clients' cash resources shall file or have on file with the licensing agency, a bond issued by a surety company to the State of California as principal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above by not having a surety bond and liability insurance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/03/2026
Plan of Correction
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Licensee has agreed to purchase Liability insurance and Surety Bond and provide proof to LPA by POC due date.
Type B
Section Cited
HSC
1507(c)(1)(B)
General Provisions
(1) For regional center clients the following shall apply: (B) The client's individualized health care plan shall be reassessed at least every 12 months or more frequently as determined by the client's physician or nurse practitioner during the time the client receives incidental medical services in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above by C1 and C3 not having updated physician reports which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/03/2026
Plan of Correction
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Licensee has agreed to schedule doctor appointments for C1 and C3, and provide proof of LIC 602A 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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Sarina Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2026


LIC809 (FAS) - (06/04)
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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: 07/03/2026
NARRATIVE
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Care & Supervision: Facility has 24 hour care staff. Staff working have criminal record clearances, and CPR/First Aid training.

Record Review: Review of (3) Client files were observed to be complete, however C1 and C3 do not have updated physician reports, deficiency issued. Review of (2) staff files were observed to be complete. Last disaster drill was conducted on 07/01/26. Facility does not have liability insurance and surety bond, deficiency issued.

Medical Related Services: Client’s medications are labeled and centrally stored in a locked cabinet. Three (3) clients medication audited, Technical assistance issued for discontinued PRN medication.

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

An exit interview was conducted where the Licensing reports (LIC 809/C, LIC 809D, LIC 9102, and appeal rights were discussed and copies of the reports were provided to House Manager Cherron Jackson at the conclusion of the visit .
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Sarina Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/03/2026 01:59 PM - It Cannot Be Edited


Created By: Sarina Ramirez On 07/03/2026 at 12:19 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: 07/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above by C2 having a broken closet door which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/03/2026
Plan of Correction
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Licensee has agreed to repair C2 closet door and provide a photo to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Sarina Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2026


LIC809 (FAS) - (06/04)
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