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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360904812
Report Date: 11/17/2025
Date Signed: 11/17/2025 11:42:17 AM

Document Has Been Signed on 11/17/2025 11:42 AM - 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:PLYMOUTH VILLAGE OF REDLANDSFACILITY NUMBER:
360904812
ADMINISTRATOR/
DIRECTOR:		MICHAEL HARRISONFACILITY TYPE:
741
ADDRESS:900 SALEM DRIVETELEPHONE:
(909) 793-1233
CITY:REDLANDSSTATE: CAZIP CODE:
92373
CAPACITY: 303CENSUS: 248DATE:
11/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Micheal Harrison Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analysts (LPAs) Edith Conchas and Renese Howell-Small made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Michael Harrison, Executive Director, and discussed the purpose of the visit.

The facility is a Continuing Care Retirement Community with independent homes, a two story assisted living unit, and a memory care unit. The facility has a license capacity of (303) residents and a hospice waiver for seven (7) residents. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant: Indoor and outdoor passageways are free of obstruction. The facility has sufficient indoor and outdoor space for resident activities. The memory care outdoor activity space is enclosed by perimeter fence gates approved by the Fire Marshall.
LPA took a tour of the facility and the resident’s bathrooms were inspected at random and operating in safe and sanitary conditions. The hot water temperature in residents' bathrooms measured between 105 to 120 degrees F. The resident’s bedrooms were inspected at random and have sufficient lighting and furniture is in good repair. The facility has operating carbon monoxide alarms, telephone service, laundry equipment and signal system. The facility has sufficient linen, towels, and personal hygiene items for residents.
Continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Edith Conchas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2025
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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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: PLYMOUTH VILLAGE OF REDLANDS
FACILITY NUMBER: 360904812
VISIT DATE: 11/17/2025
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The facility has posted in resident common areas, The Community Care Licensing complaint posters, Ombudsman posters, facility sketches, and resident monthly activities.

Food Service: Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerators and freezers are operating in a healthful manner. Pesticides and other cleaning solutions were kept locked and stored away from food areas. The facility has posted menus and sufficient dining areas for residents.

Care & Supervision: The facility has 24-hour/7 days a week care staff and have in-house drivers to transport the residents. LPA observed several staff assisting with resident care, food service, maintenance and housekeeping.

Record Review: The facility conducted a Fire drill on 10/13/2025 and Disaster drill last conducted on 9/26/2025. Emergency Disaster Plan was last updated on 4/23/2025 due to no changes. Facility has a Manual Fire Dampers system last inspected on 11/20/2024 and next inspection due date is on 11/20/2028. The facilities Tamper switch and Water flow device inspection was tested 12/10/2024.
Six (6) staff files were reviewed at random and were observed to be complete and included criminal record clearances or exemptions through the Department. Six (6) residents files reviewed at random were observed to be complete.

Medical Related Services: All medication was centrally stored and kept locked in the medication room and appeared to be dispensed as prescribed by their physicians.

Based on LPA observations and file review, the facility is in compliance with Title 22 regulations and no deficiencies were cited during today's visit.

An exit interview was conducted at the conclusion of the visit and a copy of this report was provided to the Executive Director at the conclusion of the visit with appeal rights..
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Edith Conchas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025
LIC809 (FAS) - (06/04)
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