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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880951
Report Date: 01/09/2026
Date Signed: 01/09/2026 01:32:51 PM

Document Has Been Signed on 01/09/2026 01:32 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:CHERRY & PINE GARDEN HOME CAREFACILITY NUMBER:
361880951
ADMINISTRATOR/
DIRECTOR:		MANGANGEY, GLORIA ANNEFACILITY TYPE:
740
ADDRESS:7610 I AVENUETELEPHONE:
(442) 800-5502
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 6CENSUS: 4DATE:
01/09/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Glory Anne Mangangey/Jovelyn SingsonTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Magda Malcore and Rima Corona made an unannounced visit to the facility to conduct a required annual inspection. LPAs met with Administrator Gloria Anne Mangangey and Staff Jovelyn Singson and discussed the purpose of the visit.

The facility is a 3 bedroom, 3 bathroom, Residential Care Facility for the Elderly (RCFE) with a license capacity of (6) and a current census of (4) residents in care. LPAs conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility has no swimming pools or similar bodies of water. Outdoor shaded area is sufficient for resident activities and is enclosed with a self-latching gates. The facility has sufficient lighting, books, magazines, games, and activity space for residents. The facility is maintained at a comfortable temperature of 71 degrees Fahrenheit(F). Resident’s bathroom equipment were fully operational and bathrooms were equipped with grab rails and slip mats. The hot water temperature in residents' bathrooms measured 105 degrees F. Resident’s bedrooms audited had sufficient lighting, bed linen and furniture in good repair. The facility is equipped with fire/carbon monoxide alarms, fully charged fire extinguishers, laundry equipment, two (2) covered fireplaces and telephone service. The facility has sufficient towels, and personal hygiene items for residents. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, Personal Rights, facility license, disaster evacuation plan and emergency telephone numbers. Sharp knives and scissors were kept lock. LPAs observed a disinfectant spray was stored unlocked in the bathroom located near the kitchen area. A deficiency cited.

Food Service: Facility kitchen and dining areas were maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. The facility has sufficient clean cups, plates, and utensils for residents.
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Magda Malcore
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2026
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.

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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: CHERRY & PINE GARDEN HOME CARE
FACILITY NUMBER: 361880951
VISIT DATE: 01/09/2026
NARRATIVE
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Care & Supervision: Facility has 24-hour, 7 days a week care staff. Staff working have criminal records clearances through the Department.

Record Review: The facility's Administrator certification and liability insurance is current. Four (4) resident files were observed to be complete. Review of four (4) staff reveals that Staff 1 (S1),Staff 2 (S2) and Staff 3 (S3) who assist with medication did not have annual medication training and annual dementia training on file. The Licensee also did not maintain record of current staff quarterly disaster drill training on file.

Medical Related Services: Resident’s medications are centrally stored in a locked cabinet. The facility has a complete first aid kit with manual.

Based on observations and record review, deficiencies are being cited and technical advisories were issued per Title 22, Division 6 of The California Code of Regulations (CCR) and Health & Safety Code (HSC).

This report and correction plans were reviewed with Staff Singson and copies with Appeal Rights were provided at the conclusion of the visit.
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Magda Malcore
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/09/2026 01:32 PM - It Cannot Be Edited


Created By: Magda Malcore On 01/09/2026 at 12:12 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: CHERRY & PINE GARDEN HOME CARE
FACILITY NUMBER: 361880951

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observations, the licensee did not comply with the section cited above by disinfectant spray in bathroom located near the kitchen area was stored unlocked and accessible to residents; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2026
Plan of Correction
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Facility staff removed the disinfectant spray from the bathroom and placed it in a locked cabinet. No further action required.
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:
Magda Malcore
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/09/2026 01:32 PM - It Cannot Be Edited


Created By: Magda Malcore On 01/09/2026 at 12:12 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: CHERRY & PINE GARDEN HOME CARE
FACILITY NUMBER: 361880951

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs records review, the licensee did not comply with the section cited above by Staff 1 (S1), Staff 2 (S2) and Staff 3 (S3) do not have annual dementia training on file; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2026
Plan of Correction
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The Licensee/Administrator has agreed to conduct dementia training with staff and provide documentation of training to the Licensing Agency by Plan of Correction (POC) due date.
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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Based on LPAs record review, the licensee did not comply with the section cited above by not having record of staffs quarterly disaster drill training on file; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2026
Plan of Correction
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The Licensee/Administrator has agreed to conduct staff disaster drill training and provide documentation of training to the Licensing Agency by Plan of Correction (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: 01/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/09/2026 01:32 PM - It Cannot Be Edited


Created By: Magda Malcore On 01/09/2026 at 12:47 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: CHERRY & PINE GARDEN HOME CARE
FACILITY NUMBER: 361880951

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(b)
(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs record review, the licensee did not comply with the section cited by by Staff 1 (S1),Staff 2 (S2) and Staff 3 (S3) who assist with medication did not have annual medication training on file; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2026
Plan of Correction
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The Licensee/Administrator stated that they will provide medication management training to staff and provide documentation of training to the Licensing Agency by Plan of Correction (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:
Magda Malcore
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2026


LIC809 (FAS) - (06/04)
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