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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881246
Report Date: 05/19/2026
Date Signed: 05/19/2026 03:25:30 PM

Document Has Been Signed on 05/19/2026 03:25 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:ORCHARD SENIOR LIVINGFACILITY NUMBER:
361881246
ADMINISTRATOR/
DIRECTOR:		GUEVARRA, MARYDESFACILITY TYPE:
740
ADDRESS:4287 ORCHARD STTELEPHONE:
(213) 618-0938
CITY:MONTCLAIRSTATE: CAZIP CODE:
91763
CAPACITY: 6CENSUS: 4DATE:
05/19/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:John Belleza caregiverTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
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On 5/19/2026 at 11:20 AM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA met with Caregiver John Belleza and was granted entry to the facility. At the time of the visit there were two (2) staff present, and four (4) residents present.

The facility is a five (5) bedrooms, two (2) bathroom home with a kitchen/dining area, living room/activity room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) non-ambulatory and six (6) hospice care waiver and the current census is four (4) residents. LPA was accompanied by a staff 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 Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 79 degrees Fahrenheit. LPA inspected resident bedrooms; they are equipped with the 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. LPA measured and observed the water temperatures in the bathroom to be at 144 degrees Fahrenheit. Deficiency issued. The facility is equipped with a combined operating smoke detectors and carbon monoxide alarms. Fire extinguisher was also observed at the facility.LPA observed the fire extigushers were not certified. Deficiency issued. Posters such as personal rights, the CCLD complaint poster. and the disaster plan was posted in a common area. LPA observed that the facility do not have an activity calendar posted. Deficiency issued.
***Continuation in LIC809C ***
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Eldin Serrano
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2026
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ORCHARD SENIOR LIVING
FACILITY NUMBER: 361881246
VISIT DATE: 05/19/2026
NARRATIVE
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Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. LPA observed that one of the lock in the cabinet that store the chemicals is broken. Deficiency issued. There was a designated storage space for resident/staff files. There is a Medicine closet with the resident’s medications locked. LPA observed first aid kit and first aid book at the facility.

Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the right side of the house that leads into the backyard, two (2) car shaded carport observed. All outdoor pathways were free of obstructions.


Food Service: Seven (7) days’ supply of Non-perishable foods and two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care.

Care & Supervision: The facility has sufficient number of staff to provide care and supervision to the residents in care.

Record Review: LPA reviewed two (2) resident files for admission agreements, physician reports, pre-placement appraisals and needs and services plans. LPA observed resident #1 (R1) and #2 (R2) do not have an updated physicians report. Deficiency issued. LPA observed that the medication record of R1 and R2 is not updated and not logged in correctly. Deficiency will be issued. LPAs reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings.

Based on the observations made during today’s visit, seven (7) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report LIC809, LIC809C, LIC809D forms, and Appeal Rights were discussed and provided to caregiver John Belleza.
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Eldin Serrano
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/19/2026 03:25 PM - It Cannot Be Edited


Created By: Eldin Serrano On 05/19/2026 at 02:49 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: ORCHARD SENIOR LIVING
FACILITY NUMBER: 361881246

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,, the licensee did not comply with the section cited above by not ensuring that the cabinet lock where the chemicals are stored is not broken which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2026
Plan of Correction
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2
3
4
Licensee will submit pictures of the cabinet door lock is fixed on plan of correction (POC) due date.
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(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 observation, the licensee did not comply with the section cited above by not ensuring that the client bathroom hot water faucet delivers water temperature taht is within the required range. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2026
Plan of Correction
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Licensee will submit picture of the hot water faucet temperature that is within the regulation on 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:
Eldin Serrano
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/19/2026 03:25 PM - It Cannot Be Edited


Created By: Eldin Serrano On 05/19/2026 at 02:49 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: ORCHARD SENIOR LIVING
FACILITY NUMBER: 361881246

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not ensuring that the fire extiguishers have the certification to determined if it is operable which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2026
Plan of Correction
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Licensee will submit proof of certification of the fire extiguishers on plan of correction (POC) due date.
Type B
Section Cited
CCR
87219(a)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that the facility has an activity calendar for the resident to participate to encouraged to maintain and develop their quality of life. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2026
Plan of Correction
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Licensee will submit a copy of the facility activity calendar on 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:
Eldin Serrano
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 05/19/2026 03:25 PM - It Cannot Be Edited


Created By: Eldin Serrano On 05/19/2026 at 02:49 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: ORCHARD SENIOR LIVING
FACILITY NUMBER: 361881246

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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, interview, record review, the licensee did not comply with the section cited above by not ensuring that resident #1 (R1) and #2 (R2) medications are properly logged in the medication administration record which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2026
Plan of Correction
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LIcensee to submit medication training by a licensed professional signed by all staff and the person that conducted the training by plan of correction (POC) due date.
Type B
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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4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that resident #1 (R1) and #2 (R2) have an updated physician's report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2026
Plan of Correction
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2
3
4
 Licensee will submit an updated physicians report or proof of doctor's appointment to perform the medical assesment on 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:
Eldin Serrano
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/19/2026 03:25 PM - It Cannot Be Edited


Created By: Eldin Serrano On 05/19/2026 at 02:49 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: ORCHARD SENIOR LIVING
FACILITY NUMBER: 361881246

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 record review, the licensee did not comply with the section cited above that the facility has an updated disaster drill available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2026
Plan of Correction
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2
3
4
Licensee will submit an updated disaster drill signed by all staff on plan of correction (POC) due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:
Eldin Serrano
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2026


LIC809 (FAS) - (06/04)
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