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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336427411
Report Date: 02/22/2024
Date Signed: 02/22/2024 02:06:38 PM


Document Has Been Signed on 02/22/2024 02:06 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:EASTVALE BOARD AND CAREFACILITY NUMBER:
336427411
ADMINISTRATOR:ALCAZAR, ANTONIOFACILITY TYPE:
740
ADDRESS:13968 AGATE CTTELEPHONE:
(951) 427-5477
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:6CENSUS: 6DATE:
02/22/2024
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Simm & Brooke SanasinhTIME COMPLETED:
02:07 PM
NARRATIVE
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On this day, Licensing Program Analysts (LPAs) Anna Bueno and Bianca Wolcott conducted an announced pre-licensing inspection of the facility. LPAs met with facility staff Simm Sanasinh.

During the pre-licensing inspection review of resident records, it was discovered that the facility is operating over capacity and in violation of its license limitations. The facility is currently licensed for six ambulatory residents. Through records reviewed, LPAs found non-ambulatory residents. This poses an immediate health and safety risk to residents in care. This will result in an immediate civil penalty of $500. Refer to LIC809-D for deficiency cited.

Licensees and administrators Kristi Isenberg and Antonio Alcazar were not present to sign this report.
An exit interview was conducted with and a copy of this report, LIC809D, LIC421IM, and appeal rights were provided to staff Sanasinh.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 02/22/2024 02:06 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: EASTVALE BOARD AND CARE
FACILITY NUMBER: 336427411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/23/2024
Section Cited
CCR
87204(b)

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87204: Limitations - Capacity & Ambulatory Status (b) Resident rooms approved for 24-hr care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents.
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Licensee shall remove non-ambulatory residents from ambulatory only rooms no later than the end of POC date.
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This requirement was not met as evidenced by:

Through resident records reviewed, residents in care are non-ambulatory. This poses an immediate health and safety risk to residents 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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2