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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426125
Report Date: 07/08/2026
Date Signed: 07/08/2026 03:51:17 PM

Document Has Been Signed on 07/08/2026 03:51 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:MOTHERLY CAREFACILITY NUMBER:
336426125
ADMINISTRATOR/
DIRECTOR:		ARQUISOLA, AUREAFACILITY TYPE:
740
ADDRESS:35496 PRARIE RD.TELEPHONE:
(951) 609-1824
CITY:WILDOMARSTATE: CAZIP CODE:
92595
CAPACITY: 3CENSUS: 2DATE:
07/08/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Director/Administrator Aurea ArquisolaTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Andrew Martinez made an unannounced visit to conduct a required annual comprehensive inspection of the facility. LPA Martinez met with, explained the purpose of the visit to, and was granted entry into the facility by Director/Administrator Aurea Arquisola. Two (2) staff and (2) residents were present at time of visit.

Facility is operating in the capacity approved by Community Care Licensing Division (CCLD); licensed for capacity of three (3) residents-- fire clearance for one (1) ambulatory and two (2) non-ambulatory, (1) of which can be bedridden in Room #1. Facility has hospice waiver for (3). LPA was accompanied by Director/ Administrator Arquisola to conduct a general inspection, which included, but was not limited to the following:

Physical Plant: The facility is a five (5) bedroom, two (2) bathroom home with a kitchen/dining area, living room/activity room, laundry area and attached two (2) car garage. LPA observed bedrooms designated for resident’s use are rooms #1 and #2; Bedrooms #3, #4, and #5 are being used by Licensee and family; all adults residing in home have appropriate criminal background clearances and associations to facility. LPA observed no obstructions to indoor passageways. Obstructions to outdoor passageway observed on left side of house. Technical Violation (TV) deficiency to be issued. The facility indoor temperature was maintained at a comfortable 75 degrees Fahrenheit. LPA inspected resident bedrooms to be equipped with sufficient lighting as well as required furniture (e.g., mattresses, nightstands and storage space). LPA observed bathrooms were clean and appliances were operating appropriately. LPA observed grab bars and non-skid mat in the resident bathrooms. Hot water temperatures measured at 107.2, 112.1, and 106.4 degrees Fahrenheit. The facility maintains an adequate supply of extra linens and towels.
*** Continued on LIC 809C ***
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Andrew Martinez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2026
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.

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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: MOTHERLY CARE
FACILITY NUMBER: 336426125
VISIT DATE: 07/08/2026
NARRATIVE
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LPA observed a sufficient supply of hygiene items stored for residents use. The facility has sufficient furniture and space at the facility to accommodate persons in care. The facility is equipped with operating combined smoke detectors and carbon monoxide alarms. Posters such as personal rights, Ombudsman Poster and the Emergency Disaster plan were posted in a common area. LPA observed the CCLD complaint poster to be the incorrect size per regulation, and there was no conspicuous posting of the facility's approved admissions agreement. Two (2) TV deficiencies will be cited. There was a designated storage space for resident/staff files, and a cabinet with the resident’s medications locked in the hallway.

Food Service: Seven (7) days non-perishable and two (2) days perishable food supply observed at the facility. LPA observed frozen foods in storage freezer located in garage to be improperly stored, in uncovered containers. A TV deficiency will be issued.

Care & Supervision: The facility has an administrator present in the facility during the visit and the facility's LIC 500 indicated staff are scheduled for 24/7 care and supervision of residents in care. However, Director/Administrator Arquinsola was unable to provide documentation that indicates (1) of (2) staff persons scheduled to work the night shift are qualified to provide night supervision, are familiar with the facility's planned emergency procedures, and no have proof that staff persons are trained in first aid. One (1) type A deficiency will be issued.

Resident Record Review: LPA reviewed (2) resident files for admission agreements, updated physician reports, pre-placement appraisal, centrally stored medication list and needs and services plans. LPA observed that Director/Administrator Arquinsola has not completed the required Reappraisals or Needs and Services Plans for (2) of (2) residents. Two (2) type B deficiencies will be issued. LPA audited medications for (2) of (2) residents and observed medications and records to be completed and dispensed accurately.

Staff Record Review: LPA requested review of personnel files for (4) of (4) staff listed on facility's LIC 500 for First Aid/CPR certification, criminal record clearance, training, and health screenings with tuberculosis (TB) test results. Director/Administrator indicated that (2) of (4) persons listed on LIC 500 do not have personnel files, and therefore there is no documentation of Health Screening records of (2) staff. Two (2) type A deficiencies will be issued. LPA also observed (4) out of (4) staff do not have valid/unexpired First Aid/CPR certifications. Another type A deficiency will be issued.


*** Continued on LIC 809C ***
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Andrew Martinez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2026
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: MOTHERLY CARE
FACILITY NUMBER: 336426125
VISIT DATE: 07/08/2026
NARRATIVE
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Facility Record Review: LPA reviewed facility's quarterly disaster drill records which revealed the facility has only conducted fire drills for over the past year, has not varied the type of drill from quarter to quarter to take into account different emergency scenarios, and has not included all personnel listed on the facility's LIC 500. One (1) TV deficiency will be issued. LPA observed current liability insurance for facility.

Based on today's observation, interviews and record review, four (4) type A, two (2) type B, and five (5) Technical Violation (TV) deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations

An exit interview was conducted where this Facility Evaluation Report (LIC 809), Deficiency & Plans of Correction (LIC 809D), Technical Violations/Assistances (LIC 9102), and Appeal Rights, were discussed with and copies provided to Director/Administrator Aurea Arquisola.
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Andrew Martinez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2026
LIC809 (FAS) - (06/04)
Page: 4 of 17
Document Has Been Signed on 07/08/2026 03:51 PM - It Cannot Be Edited


Created By: Andrew Martinez On 07/08/2026 at 03:01 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: MOTHERLY CARE
FACILITY NUMBER: 336426125

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in [4] out of [4] staff persons indicated on LIC 500 do not posses valid/unexpired CPR/First Aid training certifications which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2026
Plan of Correction
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Licensee to renew and obtain CPR training and first aid training for at least one staff member who will be on duty and on the premises at all times. Licensee also to review regulation in full and submit a signed statement of understanding along with valid CPR/First Aid training certification to Licensing via email by close of business (COB) on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
87415(a)(1)
Night Supervision
(a) The following persons providing night supervision from 10:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services, and shall be available as indicated below to assist in caring for residents in the event of an emergency: (1) In facilities caring for less than sixteen (16) residents, there shall be a qualified person on call on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, licensee did not comply with section cited above by not supplying Licensing with documentation that ensures (1) of (2) staff scheduled to work night shift are qualified individuals familiar with the facility's planned emergency procedures, trained in first aid, and available to assist in caring for residents in the event of an emergency which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2026
Plan of Correction
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Licensee to updated facility's Personnel Report (LIC500) that scheudles additional qualified staff to work the night shift as required and submit a copy via email to Licensing by COB on POC due date. Or Licensee is to compile a full personnel record for staff scheduled during night shift to incorporate all required documentation required by regulation completed in full, and submit documentation to Licensing via email by COB on 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:
Andrew Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/08/2026 03:51 PM - It Cannot Be Edited


Created By: Andrew Martinez On 07/08/2026 at 03:01 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: MOTHERLY CARE
FACILITY NUMBER: 336426125

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

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 ensuring [2] out of [4] persons listed on LIC 500 to provide care and supervision of residents have health screenings performed by a physician which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2026
Plan of Correction
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Licensee to have all facility staff that provide care and supervision to persons in care shown on LIC 500 to obtain health screenings performed by a physciain and provide completed health screenings to Licensing by close of business (COB) on Plan of Correction (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:
Andrew Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/08/2026 03:51 PM - It Cannot Be Edited


Created By: Andrew Martinez On 07/08/2026 at 03:01 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: MOTHERLY CARE
FACILITY NUMBER: 336426125

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(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 maintaining personnel records for (2) of (4) employees listed on facility's LIC 500 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2026
Plan of Correction
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Licensee to compile and maintain complete personnel record files for (2) of the (4) employees listed on facility's LIC 500 and provide proof of files with documents completed in full to Licensing via email by close of business (COB) on Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Andrew Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2026


LIC809 (FAS) - (06/04)
Page: 7 of 17
Document Has Been Signed on 07/08/2026 03:51 PM - It Cannot Be Edited


Created By: Andrew Martinez On 07/08/2026 at 03:01 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: MOTHERLY CARE
FACILITY NUMBER: 336426125

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above ensuring [2] out of [2] residents has the required annual Reappraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2026
Plan of Correction
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LIcensee stated to submit completed Reappraisal for (2) out of (2) residents to Licensing by close of business (COB) on Plan of Correction (POC) due date.
Type B
Section Cited
HSC
1569.695(e)(2)
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, interview, and record review, the licensee did not comply with the section cited above by ensuring an appraisal of resident needs and services plans for [2] out of [2] residents was completed annually and readily available for facility staff in the event of an emergency which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2026
Plan of Correction
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2
3
4
LIcensee stated to submit completed needs and services plans for (2) out of (2) residents to Licensing by COB on 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:
Andrew Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2026


LIC809 (FAS) - (06/04)
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