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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426057
Report Date: 01/03/2025
Date Signed: 01/03/2025 11:38:43 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/02/2025 and conducted by Evaluator Raquel Hernandez
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250102114408
FACILITY NAME:EASTVALE SENIOR HOME CAREFACILITY NUMBER:
336426057
ADMINISTRATOR:ADELAIDA BADILLOFACILITY TYPE:
740
ADDRESS:14394 HEALY LAKE STREETTELEPHONE:
(951) 356-5270
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:6CENSUS: 6DATE:
01/03/2025
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Staff Victoria OchavaTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Resident record is not completed.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Raquel Hernandez conducted an unnannounced visit for the purpose of investigating the above allegation. LPA met with Staff Victoria Ochava and explained the purpose of the visit. The investigation consisted of facility tour and record review.

For the allegation, Resident record are not completed. LPA Hernandez conducted a record review for former Client #1 (C1). During record review LPA observed no admission agreement for C1 or a completed record.

Based on observations and record review, the allegation is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. During today’s visit, a deficiency was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report LIC9099, LIC9099C and LIC9099D were discussed and provided to Licensee Laarni Dizon along with a copy of appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Raquel HernandezTELEPHONE: 951-248-0336
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 56-AS-20250102114408
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 SENIOR HOME CARE
FACILITY NUMBER: 336426057
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2025
Section Cited
CCR
87506(a)
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(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
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Licensee and staff will read Title 22 regulation 87506 regarding Resident Records and send photo documentation confirming regulation was read by Plan of Correction (POC) due date. Additionally, licensee stated to not accept future residents with incomplete record.
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Based on observation and record review, licensee did not not comply with the section cited above by not ensuring former Client #1 (C1) had a completed record prior to moving into the facility, which poses a poential health, saftey, or personal rights risk to persons in care.
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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.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Raquel HernandezTELEPHONE: 951-248-0336
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2