361881026-1-16-2026-56-AS-MMAE-DQDPWH-20260116104045

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881026
Report Date: 01/16/2026
Date Signed: 01/16/2026 10:40:59 AM

Document Has Been Signed on 01/16/2026 10:40 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	HESPERIA SENIOR CARE		FACILITY NUMBER:	361881026
ADMINISTRATOR/ DIRECTOR:	WANG, JIN A		FACILITY TYPE:	740
ADDRESS:	17583 SULTANA STREET		TELEPHONE:	(760) 669-0109
CITY:	HESPERIA	STATE: CA	ZIP CODE:	92345
CAPACITY: 18		CENSUS: 10	DATE:	01/16/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:05 AM
MET WITH:	Raeann Rios		TIME VISIT/ INSPECTION COMPLETED:	10:50 AM

NARRATIVE

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Licensing Program Analysts (LPAs) Magda Malcore and Rima Corona made an unannounced visit to conduct a required comprehensive annual inspection. LPAs met with Facility Manager, Raeann Rios and informed the purpose of the visit. The facility is Residential Care Facility for Elderly (RCFE). The facility's license capacity is (18) with a current census of (10). LPAs conducted a general inspection of the facility, which included, but was not limited to, the following:

Physical Plant: The facility has no obstructions to indoor and outdoor passageways. The facility is maintained at a 72 degrees Fahrenheit (F). The facility's outdoor activity area is enclosed with a latching gate. The facility is equipped with operating smoke/carbon monoxide alarms, two (2) fully charge fire extinguishers, laundry equipment, and telephone service. The facility has posted in a common area: Community Care Licensing Complaint poster, Ombudsman poster, emergency telephone numbers, facility menu, activities, theft and loss policy, and "Oxygen in use" signs. Cleaning supplies, toxins, and sharps were kept inaccessible to residents in care. LPAs inspected five (5) resident bedrooms which were equipped with beds, bed linen, night stands, chairs and sufficient lighting. LPAs inspected five (5) resident bathrooms which were equipped with grab rails and slip mats. Bathroom hot water temperatures measured 106 degrees (F).

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. The facility has sufficient cups, plates, and utensils for residents in care. The facility's refrigerators and freezers were operating in a healthful manner.

Care & Supervision: The facility's staff schedule reflects care coverage 24 hours a day, 7 days a week. All staff working in the facility have criminal record clearance through the department.

Health Related Services: The facility maintains record of resident’s medications and first aid kit. Medications were centrally store in a locked room.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Magda Malcore
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2026

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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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: HESPERIA SENIOR CARE	FACILITY NUMBER: 361881026
	VISIT DATE: 01/16/2026

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Record Review: Five (5) resident files reviewed had admission agreements, medical assessments, and appraisals. Five (5) staff files reviewed had First Aid/CPR certifications, criminal record clearances, training, and health screenings. The facility had a emergency disaster plan, infection control plan, liability insurance and staff disaster drill training for review.

No deficiencies were issued during today's visit. An exit interview was conducted, where this report was discussed and a copy provided to Facility Manager Rios.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Magda Malcore
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2026

LIC809 (FAS) - (06/04)

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