<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800461
Report Date: 04/06/2026
Date Signed: 04/06/2026 01:46:32 PM

Document Has Been Signed on 04/06/2026 01:46 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SKIOMAH ROADFACILITY NUMBER:
361800461
ADMINISTRATOR/
DIRECTOR:		SHARDE CARR, ERICAFACILITY TYPE:
735
ADDRESS:13159 SKIOMAH ROADTELEPHONE:
(818) 309-7821
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 6CENSUS: 4DATE:
04/06/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Reba JordanTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Administrator Reba Jordan and discussed the purpose of the visit. The facility is an Adult Residential facility with a license capacity of (6) and a current census of (4). The facility is a certified Inland Regional Center (IRC) vendor. During today's visit there were no clients present. LPA conducted an overall inspection, which included, but was not limited to, the following:

Operation/Physical Plant: The facility is operating within the license limitations approved by Community Care Licensing Division (CCLD). Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor activity space for clients in care. Backyard activity space is covered and enclosed with a latching gate. LPA observed in the backyard an insect killer chemical left outside unlocked and unattended. Indoor facility temperature is maintained at 72 degrees fahrenheit (F). The facility is equipped with fire/carbon monoxide alarms, fire extinguisher, laundry equipment, emergency food/water and covered fire place. The facility has posted: Disaster plan with emergency telephone numbers, administrator's certification, facility license, client personal rights, and facility sketch. Client bedrooms were equipped with beds, bed linen, dressers, storage space and lighting. Client bathroom water temperature tested at 105 degrees (F). LPA observed the one of bathroom shower with access to visitors, clients, and staff was not maintained clean and not in good repair. The shower head equipment was leaking causing a puddle in shower. LPA also observed the shower door and shower wall had heavy soap residue.

Food Service: The facility’s kitchen and dining areas were maintained clean. The facility maintains a (7) day supply of non-perishable food, (2) day supply of perishable food, and snacks for clients in care. The facility’s refrigerator, freezer, and food pantry provided sufficient space for food storage.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Magda Malcore
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2026
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 7
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)
Page: 2 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SKIOMAH ROAD
FACILITY NUMBER: 361800461
VISIT DATE: 04/06/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Health Related Services: Client medications are centrally stored and kept locked. The facility maintains a first aid kit with manual. LPA conducted an audit of clients medications. LPA observed Client#1 (C1's) medications were transferred and stored into weekly pills box container. Staff present stated that they transferred the medications into the pill box container as requested by C1's family member.

Personnel/Client Records: Four (4) staff records were reviewed for personnel history, orientation, health screenings, criminal record clearances, and first aid/CPR training certifications. Four (4) client records were reviewed for admission agreements, medical assessments, needs and service plans, and personal/incidental logs (P&I). The facility maintains liability insurance, surety bond, client registry, disaster and infection control plan for review.

Deficiencies have been cited in accordance with Title 22, Division 6, of the California Code of Regulations (CRC).

An exit interview was conducted. Copies of reports (LIC809, LIC809C, LIC809D) and appeal right have been provided to Administrator Jordan.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Magda Malcore
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2026
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 04/06/2026 01:46 PM - It Cannot Be Edited


Created By: Magda Malcore On 04/06/2026 at 12:36 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: SKIOMAH ROAD
FACILITY NUMBER: 361800461

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPAs observations, the licensee did not comply with the section cited above in by insect killer chemical was left outside unlocked and unattended; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2026
Plan of Correction
1
2
3
4
Correction: facility removed the insect killer chemical and stored it locked.
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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Magda Malcore
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2026


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 04/06/2026 01:46 PM - It Cannot Be Edited


Created By: Magda Malcore On 04/06/2026 at 12:36 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: SKIOMAH ROAD
FACILITY NUMBER: 361800461

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observations, the licensee did not comply with the section cited above by having a leaky shower head, heavy soap residue on shower walls and doors in one of bathrooms with access to clients, staff and visitors; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/20/2026
Plan of Correction
1
2
3
4
The Licensee shall provide proof of fixed leak and cleaned bathroom to the licensing agency by 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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Magda Malcore
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 04/06/2026 01:46 PM - It Cannot Be Edited


Created By: Magda Malcore On 04/06/2026 at 12:36 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: SKIOMAH ROAD
FACILITY NUMBER: 361800461

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Type B
Section Cited
CCR
80075(k)(5)
(k) The following requirements shall apply to medications which are centrally stored: (5) Each client's medication shall be stored in its originally received container.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPAs observations, the licensee did not comply with the section cited above by storing Client#1 (C1's) medication in a weekly pill box container and not in their original bottle; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/20/2026
Plan of Correction
1
2
3
4
The Licensee shall retrain/conduct in service medication management training to staff and provide proof of training to the licensing agency by 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:
Magda Malcore
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2026


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 04/06/2026 01:46 PM - It Cannot Be Edited


Created By: Magda Malcore On 04/06/2026 at 12:36 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: SKIOMAH ROAD
FACILITY NUMBER: 361800461

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(6)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (6) No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPAs observations, the licensee did not comply with the section cited above by facility staff transferred Client#1(C1's) prescribed medications from their original container into weekly pill box container; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/20/2026
Plan of Correction
1
2
3
4
The Licensee shall retrain/conduct in service medication management training to staff and provide proof of training by 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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Magda Malcore
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2026


LIC809 (FAS) - (06/04)
Page: 7 of 7