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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880928
Report Date: 09/18/2025
Date Signed: 09/18/2025 12:26:02 PM

Document Has Been Signed on 09/18/2025 12:26 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:MAE WEST HOME CARE LLCFACILITY NUMBER:
361880928
ADMINISTRATOR/
DIRECTOR:		LANETT ADAMSFACILITY TYPE:
735
ADDRESS:35544 MT. VIEW STREETTELEPHONE:
(909) 570-4758
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY: 4CENSUS: 1DATE:
09/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Licensee La Nett Adams TIME VISIT/
INSPECTION COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Edith Conchas and Sarina Ramirez visited the facility unannounced to complete a comprehensive annual inspection. LPAs met with Licensee, La Nett Adams and explained the purpose of the visit.

The facility is an Adult Residential Facility (ARF) licensed for a capacity of four (4) ambulatory clients. The facility is a level 6, vendorized through Inland Regional Center (IRC). The current census is one (1) client. LPA was accompanied to conduct a general overall inspection, which included, but was not limited to the following:

The facility is a four (4) bedroom and two-half (2.5) bathrooms. The facility also has kitchen/dining area, living area and attached garage.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature at 75 degrees Fahrenheit.

LPA inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. The water was measured at 107.6 degrees Fahrenheit.

LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors, fully charged fire extinguisher, and carbon monoxide detectors. Posters such as personal rights, the CCL complaint poster, the Emergency disaster plan, activities calendar, house rules, personnel report, and Facility sketch plan were posted in a common area.

Continue LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Edith Conchas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2025
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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Document Has Been Signed on 09/18/2025 12:26 PM - It Cannot Be Edited


Created By: Edith Conchas On 09/18/2025 at 11:20 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: MAE WEST HOME CARE LLC
FACILITY NUMBER: 361880928

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews and record review, the licensee did not comply with the section cited above by allowing a staff to work without prior criminal record or background clearance. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2025
Plan of Correction
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Licensee immediatly excused staff (S1) and sent staff to begin the process to be cleared for employment. Licensee has agreed to submit the required prerequisite to the Department by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Edith Conchas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/18/2025 12:26 PM - It Cannot Be Edited


Created By: Edith Conchas On 09/18/2025 at 11:20 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: MAE WEST HOME CARE LLC
FACILITY NUMBER: 361880928

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85165(b)(2)
Emergency Intervention Staff Training
(b) Staff who use, participate in, approve or provide visual checks of manual restraint or seclusion, shall have a minimum of sixteen hours of emergency intervention training and be certified for having successfully completed the training. (2) Staff shall maintain valid certification.

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 based on four (4) staff files reviewed, all four staff had the Emergency Intervention certificates (CPI) training expired which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2025
Plan of Correction
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Licensee agreed to submit an email confirmation upon scheduled CPI training date. Upon completion of training, Licensee will submit a copy of certification for all staff.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Edith Conchas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: MAE WEST HOME CARE LLC
FACILITY NUMBER: 361880928
VISIT DATE: 09/18/2025
NARRATIVE
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Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care in a locked closet.

LPA observed there was a designated storage space for resident/staff files. Medications are kept locked in hallway closet inaccessible to residents in care. Medications were audited at random and appeared to be dispensed appropriately by staff members. Overall, the facility is clean, in good repair, and operates in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for the number of residents in care.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members but one (1) (S1) working in the facility have criminal record clearance through the department, a citation is issued.

Record Review: LPA reviewed one (1) resident files for admission agreements, updated physician reports, and needs and services plans.

LPA also reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Four (4) CPI certifications were expired for S 2,3,4,5, A deficiency issued.

Based on the observations made during today’s visit, two deficiencies were cited.

An exit interview was conducted, and this report was discussed and provided to Licensee La Nett Adams at the conclusion of the visit with appeal rights.

Continue LIC 809-D, LIC 421BG

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Edith Conchas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
LIC809 (FAS) - (06/04)
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