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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880936
Report Date: 10/07/2026
Date Signed: 10/07/2026 12:29:22 PM

Document Has Been Signed on 10/07/2026 12:29 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:ACTIVE BOARD AND CAREFACILITY NUMBER:
361880936
ADMINISTRATOR/
DIRECTOR:		RAMOS, ISABELITA DEFACILITY TYPE:
740
ADDRESS:1396 N. 1ST AVE.TELEPHONE:
(951) 818-1140
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY: 6CENSUS: 4DATE:
10/07/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Maria Roweena Abelido-House ManagerTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Paola Guerrero made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with House Manager Maria Roweena Abelido and was granted entry to the facility. At the time of the visit there was two (2) staff present, and four (4) residents present. The facility is a four (4) bedroom, three (3), bathroom home, with a kitchen/dining area, living room, with an attached garage. The facility is a Residential Care Facility for Elderly (RCFE) Licensed capacity is (6) current census (4). LPA was accompanied by Maria, to conduct a general overall inspection, which included, but was not limited to, the following:

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. 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. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. LPA observed an in-ground pool in the backyard, the perimeter of pool is gated and locked. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. Medications are kept inside kitchen cabinet inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for 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 working in the facility have criminal record clearance through the department.
Efren Malagon
Paola Guerrero
DATE: 10/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2026
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 10/07/2026 12:29 PM - It Cannot Be Edited


Created By: Paola Guerrero On 10/07/2026 at 11:23 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: ACTIVE BOARD AND CARE
FACILITY NUMBER: 361880936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews with staff and record review, the licensee did not comply with the section cited above by not having Medication Administration of Records for 4 out of 4 residents. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2026
Plan of Correction
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The licensee will provide training to all care staff regarding the regulation stated above and will provide proof of training to LPA. The licensee will also provide LPA with proof of administration of medication record to LPA. by POC 10/8/2026.
Type A
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews with staff and record review, the licensee did not comply with the section cited above by not having PRN Records for 4 out of 4 residents. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2026
Plan of Correction
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The licensee will provide training to all care staff regarding the regulation stated above and will provide proof of training to LPA. The licensee will also provide LPA with proof of administration of medication record to LPA. by POC 10/8/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Paola Guerrero
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/07/2026 12:29 PM - It Cannot Be Edited


Created By: Paola Guerrero On 10/07/2026 at 11:23 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: ACTIVE BOARD AND CARE
FACILITY NUMBER: 361880936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87458(c)(1)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews with staff and record review, the licensee did not comply with the section cited above by not having physician's reports on file for 4 out 4 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2026
Plan of Correction
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The licensee will provide training to all care staff regarding the regulation stated above and will provide proof of training to LPA. The licensee will also provide LPA copies of physician's reports for each resident by POC 10/8/2026.
Type A
Section Cited
CCR
87507(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews with staff and record review, the licensee did not comply with the section cited above by not having Admission Agreements on file for 4 out 4 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2026
Plan of Correction
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The licensee will provide training to all care staff regarding the regulation stated above and will provide proof of training to LPA. The licensee will also provide LPA with copies of Admission Agreeements for each resident by POC 10/8/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Paola Guerrero
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2026


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 10/07/2026 12:29 PM - It Cannot Be Edited


Created By: Paola Guerrero On 10/07/2026 at 11:23 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: ACTIVE BOARD AND CARE
FACILITY NUMBER: 361880936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(b)(1)(A)
Personal Rights of Residents
(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. (A) The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews with staff and record review, the licensee did not comply with the section cited above by not having records of signed personal rights for 4 out of 4 residents. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2026
Plan of Correction
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The licensee will provide training to all care staff regarding the regulation stated above and will provide proof of training to LPA. The licensee will also provide LPA with proof of personal rights document signed and dated by each resident and residents responsible party. By POC 10/12/2026.
Type B
Section Cited
CCR
87506(b)(17)(A)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (A) Section 87457, Pre-Admission Appraisal;

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews with staff and record review, the licensee did not comply with the section cited above by not having Pre-admission Appraisal on file for 4 out of 4 residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2026
Plan of Correction
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The licensee will provide training to all care staff regarding the regulation stated above and will provide proof of training to LPA. The licensee will also provide LPA with proof of Pre-admission Appraisals signed and dated by each resident and residents responsible party. By POC 10/12/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Paola Guerrero
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2026


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 10/07/2026 12:29 PM - It Cannot Be Edited


Created By: Paola Guerrero On 10/07/2026 at 11:23 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: ACTIVE BOARD AND CARE
FACILITY NUMBER: 361880936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.153(d)
Licensing
(d) A written resident personal property inventory is established upon admission and retained during the resident’s stay in the residential care facility for the elderly. Inventories shall be written in ink, witnessed by the facility and the resident or resident’s representative, and dated. A copy of the written inventory shall be provided to the resident or the person acting on the resident’s behalf. All additions to an inventory shall be made in ink, and shall be witnessed by the facility and the resident or resident’s representative, and dated. Subsequent items brought into or removed from the facility shall be added to or deleted from the personal property inventory by the facility at the written request of the resident, the resident’s family, a responsible party, or a person acting on behalf of a resident. The facility shall not be liable for items which have not been requested to be included in the inventory or for items which have been deleted from the inventory. A copy of a current inventory shall be made available upon request to the resident, responsible party, or other authorized representative. The resident, resident’s family, or a responsible party may list those items which are not subject to addition or deletion from the inventory, such as personal clothing or laundry, which are subject to frequent removal from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews with staff and record review, the licensee did not comply with the section cited above by not having Record of property inventory for 4 out of 4 residents. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2026
Plan of Correction
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The licensee will provide training to all care staff regarding the regulation stated above and will provide proof of training to LPA. The licensee will also provide LPA with proof of Personal Property Inventory record for 4 out of 4 residents, to LPA. by POC 10/12/2026.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Paola Guerrero
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2026


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 10/07/2026 12:29 PM - It Cannot Be Edited


Created By: Paola Guerrero On 10/07/2026 at 11:23 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: ACTIVE BOARD AND CARE
FACILITY NUMBER: 361880936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(b)
Admission Agreements
(b) The licensee shall complete and maintain in the resident's file a Telecommunications Device Notification form (LIC 9158, 11/04) for each resident whose pre-admission appraisal or medical assessment indicates he/she is deaf, hearing-impaired, or otherwise disabled in accordance with Public Utilities Code sections 2881(a) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interviews with staff and record review, the licensee did not comply with the section cited above by not having Telecommunications Device Notification form on file for 4 out of 4 residents. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2026
Plan of Correction
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The licensee will provide training to all care staff regarding the regulation stated above and will provide proof of training to LPA. The licensee will also provide LPA with proof of Telecommunications Device Notification forms for four out of four residents, to LPA. by POC 10/12/2026.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interviews with staff and record review, the licensee did not comply with the section cited above by not having having quarterly drill records on file, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2026
Plan of Correction
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2
3
4
The licensee will provide training to all care staff regarding the regulation stated above and will provide proof of training to LPA. The licensee will also provide LPA with proof of earthquake and disaster drill record, to LPA. Licensee understands that Drills will be conducted by staff quartely moving forward. POC is due on 10/12/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Paola Guerrero
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2026


LIC809 (FAS) - (06/04)
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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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ACTIVE BOARD AND CARE
FACILITY NUMBER: 361880936
VISIT DATE: 10/07/2026
NARRATIVE
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Record Review: During the review of records LPA observed the following: signed copies of resident rights were not on file for 4 out of 4 residents, Medication Administration of Records were missing for 4 out of 4 residents. PRN Record was not being maintained or kept on file, Pre-admission Appraisals were not on file for 4 out of 4 residents, 4 out 4 physician's reports were not on file, Inventory Personal Property Forms for 4 out of 4 residents were not file, Admission agreements for four residents were not on file, Telecommunication form for 4 out of 4 residents were not on file, Disaster Preparedness quarterly drills were not on file. LPA will be issuing deficiencies.

Based on the observations made during today’s visit, nine deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, were reports (LIC809) (LIC 809D) along with Appeal rights were discussed and provided to House Manager Maria Abelido.

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Paola Guerrero
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2026
LIC809 (FAS) - (06/04)
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