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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881026
Report Date: 01/08/2025
Date Signed: 01/08/2025 03:10:15 PM

Document Has Been Signed on 01/08/2025 03:10 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:HESPERIA SENIOR CAREFACILITY NUMBER:
361881026
ADMINISTRATOR/
DIRECTOR:		WANG, JIN AFACILITY TYPE:
740
ADDRESS:17583 SULTANA STREETTELEPHONE:
(760) 669-0109
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 18TOTAL ENROLLED CHILDREN: 0CENSUS: 9DATE:
01/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:35 AM
MET WITH:Jin WangTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator Jin Wang and informed the purpose of the visit. The facility is an 8 bedroom, Residential Care Facility for Elderly (RCFE) facility. The facility's license capacity is (18) with a current census of (9) . LPA 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 75 degrees F. The facility's outdoor activity area is enclosed with latching gate. The facility is equipped with operating smoke/carbon monoxide alarms, telephone service, and call button system. The facility has posted 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. LPA inspected five (5) resident bedrooms which were equipped with beds, bed linen, night stands and sufficient lighting. LPA inspected five (5) resident bathrooms which were equipped with grab rails and slip mats. LPA observed the bathroom hot water temperature in the following bedrooms tested as follows: bedroom#103 tested 132 degrees F, bedroom#104 tested 139 degrees F, bedroom #107 tested 133 degrees F, and bedroom #106 tested at 139 degrees F. Deficiency cited.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. The facility's two (2) refrigerators were operating properly at 43 degrees F.

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

Record Review: LPA reviewed three (3) resident files for admission agreements, physician reports, assessments, needs and services plans. LPA reviewed three (3) staff files for First Aid/CPR certifications, criminal record clearances, trainings, and health screenings. Resident medications were kept inaccessible to residents in care. LPA review of resident #1 (R1), resident #2 (R2) , resident #3 (R3) medication records reveals staff did not document on 1/7/25 when the medication was given for all three residents. Deficiency cited.

Karen ClemonsTELEPHONE: (951) 248-0349
Magda MalcoreTELEPHONE: 951-248-0316
DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 10
Document Has Been Signed on 01/08/2025 03:10 PM - It Cannot Be Edited


Created By: Magda Malcore On 01/08/2025 at 02:11 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: HESPERIA SENIOR CARE
FACILITY NUMBER: 361881026

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by not maintaining 4 out of 5 residents bathroom water temperature within regulation; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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The Licensee/Administrator shall submit proof that water temperatures is within regulation 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.
SUPERVISOR'S NAME:Karen Clemons
TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME:Magda Malcore
TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2025


LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 01/08/2025 03:10 PM - It Cannot Be Edited


Created By: Magda Malcore On 01/08/2025 at 02:11 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: HESPERIA SENIOR CARE
FACILITY NUMBER: 361881026

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by not documenting the dates of when medication was administered to R1, R2, and R3; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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The Licensee/Administrator shall submit a statement of understanding on the regulation cited 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.
SUPERVISOR'S NAME:Karen Clemons
TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME:Magda Malcore
TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2025


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: HESPERIA SENIOR CARE
FACILITY NUMBER: 361881026
VISIT DATE: 01/08/2025
NARRATIVE
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Deficiencies were cited and technical advisories were issued per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, where reports (LIC809, LIC809-C, LIC809-D, LIC9102) and were discussed. Copies of the reports were provided with appeal rights to the Administrator at the conclusion of the visit.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC809 (FAS) - (06/04)
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