336409877-1-14-2026-56-AS-ECOS-DQC399-20260114170246

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336409877
Report Date: 01/14/2026
Date Signed: 01/14/2026 05:03:07 PM

Document Has Been Signed on 01/14/2026 05:03 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:	CHERRY RANCH RESIDENTIAL		FACILITY NUMBER:	336409877
ADMINISTRATOR/ DIRECTOR:	DANA WALKER		FACILITY TYPE:	735
ADDRESS:	11267 CHERRY AVE.		TELEPHONE:	(951) 845-2413
CITY:	BEAUMONT	STATE: CA	ZIP CODE:	92223
CAPACITY: 6		CENSUS: 3	DATE:	01/14/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:45 PM
MET WITH:	Administrator, Adie Walker		TIME VISIT/ INSPECTION COMPLETED:	05:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) E. Conchas made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Facility administrator Adie Walker.

The facility is a three (3) bedroom, two (2), bathroom home, with a kitchen, dining area and living room. The facility is an Adult Residential Facility (ARF) level 4i home vendorized by Inland Regional Center. Licensed capacity is (6). LPA was conduct a general overall inspection, which included, but was not limited to, the following: The facility is operating in the capacity approved by Community Care Licensing (CCL).There are no obstructions to indoor and outdoor passageways. Facility does not have any bodies of water.

The facility is maintained at a comfortable temperature. LPA inspected client’s bedroom which were equipped with the required furniture including sufficient lighting. The bathrooms were in a sanitary manner and appliances were operating appropriately. LPA measured the water temperatures in the bathrooms that ranged between 121.2 -122.5 degrees F. A Technical violation was issued.

LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke alarms and a carbon monoxide detector.

Posters such as personal rights, the CCL complaint poster, and the disaster plan and facility sketch were posted in a common area.

Continye LIC 809-C, LIC 809-D.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Edith Conchas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026

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: CHERRY RANCH RESIDENTIAL	FACILITY NUMBER: 336409877
	VISIT DATE: 01/14/2026

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Most cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. LPA observed house paint that was accessible to clients. A deficiency was cited. There was a designated storage space for client/staff files. Medications are kept inaccessible to clients in care. Overall, the facility is clean, in good repair, and operating in safe conditions.

Non-perishable and perishable food supply is sufficient for number of clients in care. Emergency supply bags were observed. Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

LPA reviewed client file for admission agreements, updated physician reports, and needs and services plans. Individual Person Plan (IPP) for client 1 (C1) was not updated. A Technical was issued. Medications were audited at random and appeared to be dispensed appropriately by staff members. P&I was accounted for and matched with the ledger.

Fire drill was conducted on 12/16/2025 and Earthquake drill was conducted on 01/05/2026.

LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings.

Based on the observations made during today’s visit, technical and deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Administrator, Adie Walker with the appeal rights.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Edith Conchas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/14/2026 05:03 PM - It Cannot Be Edited

Created By: Edith Conchas On 01/14/2026 at 04:32 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: CHERRY RANCH RESIDENTIAL	FACILITY NUMBER: 336409877
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/14/2026

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/13/2026
	Plan of Correction
1 2 3 4	Administrator immedialty removed the paint buckets. Administrator will conduct a staff training on paint hazardous.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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.

	Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:

	Edith Conchas
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026

LIC809 (FAS) - (06/04)

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