336410692-1-22-2025-56-AS-RHEZ-DD6SDD-20250122124658

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336410692
Report Date: 01/22/2025
Date Signed: 01/22/2025 12:47:50 PM

Document Has Been Signed on 01/22/2025 12:47 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:	EASTVALE MEADOWS		FACILITY NUMBER:	336410692
ADMINISTRATOR/ DIRECTOR:	SIMM SANASINH		FACILITY TYPE:	740
ADDRESS:	6885 CEDAR CREEK ROAD		TELEPHONE:	(951) 520-1074
CITY:	CORONA	STATE: CA	ZIP CODE:	92880
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	01/22/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:40 AM
MET WITH:	Administrator Brooke Simm		TIME VISIT/ INSPECTION COMPLETED:	12:55 PM

NARRATIVE

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Licensing Program Analyst (LPA) Raquel Hernandez made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator Brooke Simm and was granted entry to the facility. Licensed capacity is (6) current census (5). LPA was accompanied by Administrator Brooke Simm 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 (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature at 76 degrees. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed Resident #1 (R1) to be bedridden. Facility is not licensed for bedridden residents. Deficiency will be issued. Hot water temperature tested within regulation at 113 degrees Farenheit. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated space for resident/staff files. First aid book and first aid kit were observed. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a variety of food available for residents. Dishes, cups, and utensils were also stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed (4) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans.

Efren Malagon	TELEPHONE: (951) 202-6356
Raquel Hernandez	TELEPHONE: 951-248-0336
	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

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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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: EASTVALE MEADOWS	FACILITY NUMBER: 336410692
	VISIT DATE: 01/22/2025

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LPA observed no appraisal for all residents needs and services plan. Deficiency will be issued. LPA reviewed (4) resident medications. LPA observed no PRN medication record for Resident #2 (R2). R2 has not taken any of prescribed PRN medication, however, LPA recommended to print a Medication Administration Record (MAR) for R2 when needed. Technical Assistance was issued. LPA also reviewed (4) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. No issues observed.

Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) (LIC809C) (LIC809D) and Appeal Rights was discussed and provided to Administrator Brooke Simm.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Raquel Hernandez	TELEPHONE: 951-248-0336
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/22/2025 12:47 PM - It Cannot Be Edited

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: EASTVALE MEADOWS	FACILITY NUMBER: 336410692
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Care of Bedridden Residents

(c) To accept or retain a person who is bedridden, other than for a temporary illness or recovery from surgery, a licensee shall obtain and maintain an appropriate fire clearance as specified in Section 87202, Fire Clearance. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by having a beddridden resident, Resident #1 (R1),which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/23/2025
	Plan of Correction
1 2 3 4	Licensee stated to submit LIC200 to licensing by Plan of Correction (POC) due date.

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.

Efren Malagon	TELEPHONE: (951) 202-6356
Raquel Hernandez	TELEPHONE: 951-248-0336
	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 01/22/2025 12:47 PM - It Cannot Be Edited

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: EASTVALE MEADOWS	FACILITY NUMBER: 336410692
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not ensuring all five (5) residents in care have a needs and services plan, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/07/2025
	Plan of Correction
1 2 3 4	Licensee stated to submit residents needs and services plan to LPA Hernandez by Plan of Correction (POC) due date.

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.

Efren Malagon	TELEPHONE: (951) 202-6356
Raquel Hernandez	TELEPHONE: 951-248-0336
	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC809 (FAS) - (06/04)

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