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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880850
Report Date: 08/07/2026
Date Signed: 08/07/2026 10:11:21 AM

Document Has Been Signed on 08/07/2026 10:11 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:SALEM HOMEFACILITY NUMBER:
361880850
ADMINISTRATOR/
DIRECTOR:		KARAMOY, DINAFACILITY TYPE:
735
ADDRESS:18305 SALEM LANETELEPHONE:
(760) 596-1472
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 4CENSUS: 4DATE:
08/07/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Dina Karamoy, LicenseeTIME VISIT/
INSPECTION COMPLETED:
10:25 AM
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On 8/7/2026 at 9:10AM, Licensing Program Analyst (LPA) Eldin Serrano conducted an investigation regarding an incident involving Client #1 (C1). Based on staff interviews and documentation, at approximately 12:15 a.m., C1 gained access to a locked safe located in the facility office, obtained the facility vehicle keys, and drove the facility vehicle off the property without authorization. Staff contacted law enforcement. C1 later returned the vehicle to the facility, and responding Sheriff personnel attempted to locate the keys but were unsuccessful. The Deputy informed staff that if the client attempted to remove the vehicle again, the client would be subject to immediate arrest.

The facility later notified management staff regarding the incident; however, interviews and review of the event indicated lapses in both supervision and facility property security.

Client access to secured keys, removal of the facility vehicle, and law enforcement involvement represent significant safety concerns and indicate that the facility did not ensure proper protection of facility property nor adequate supervision necessary to prevent unsafe actions by clients.

Based on the information gathered, the LPA determined the facility was in violation of Title 22 regulations related to Title 22, Section 85065 (b)– Personnel Requirements

An exit interview was conducted where this report was reviewed, discussed, and then provided to licensee Dina Karamoy.

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

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 08/07/2026 10:11 AM - It Cannot Be Edited


Created By: Eldin Serrano On 08/07/2026 at 09:51 AM
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: SALEM HOME
FACILITY NUMBER: 361880850

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/08/2026
Section Cited
CCR
85065(b)

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Title 22, Division 6 Chapter 685065 (b) Personnel Requirements
(b) The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.

This requirment is not met as evidence by:
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The licensee shall ensure all staff receive training on supervision protocols,including methods for monitoring client movement during nighttime hours and preventing unauthorized access to restricted areas. Staff will be trained in immediate reporting procedures and preventive measures to reduce client access to hazardous materials or property.
A written statement documenting completion of staff training, including the training agenda and staff attendance roster, shall be submitted to LPA by plan of correction (POC) due date..
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Staff did not provide adequate supervision to ensure client safety. The client accessed a locked safe, obtained facility vehicle keys, and operated the facility vehicle off the premises without authorization. This lack of supervision created an immediate and potential health and safety risk for the client, staff, and the public.This poses a immediate health and safety risk to clients 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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Eldin Serrano
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2026


LIC809 (FAS) - (06/04)
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