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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881321
Report Date: 07/16/2026
Date Signed: 07/16/2026 03:42:22 PM

Document Has Been Signed on 07/16/2026 03:42 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:CANYON VIEW HOMEFACILITY NUMBER:
361881321
ADMINISTRATOR/
DIRECTOR:		VERMANI, NITINFACILITY TYPE:
740
ADDRESS:9220 OLD RANCH RDTELEPHONE:
(909) 244-0286
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY: 6CENSUS: 5DATE:
07/16/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:44 AM
MET WITH:Sandy Barr, House ManagerTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On 7/16/2026 at 11:44 AM, Licensing Program Analyst (LPA) LaVette Farlow arrived unannounced to conduct the required annual visit to the facility. LPA met with House Manager Sandy Barr, and introduced self and stated purpose of the visit. LPA was informed the current census is five (5) two (2) residents were present during the visit two (2) resident were at InnovAge Day Program, and one (1) resident was visiting with family.

The facility has 4 bedrooms, 2 1/2 bathrooms, 1 staff bedroom, kitchen, dining area, family room, living room, washer and dry in the garage, attached garage, and backyard. LPA completed a walk through of facility, review of records, and medication.

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 of 76 degrees Fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. During the inspection LPA observed cleaning supplies under the bathroom sink in the staff bathroom by the kitchen. The cabinet was unlocked and not secured with chemical spray bottle and can of Ajax unsecured. A Deficiency cited. The water temperature was tested and measured at 115.5, 107.1 and 113.3 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms and charged fire extinguisher, the last fire extinguisher inspection was conducted 7/17/2025. Posters such as; the personal rights, CCL complaint poster and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept secure and inaccessible to residents. There was a designated storage space for residents/staff files. Medications and first aid kit were observed secure and inaccessible to residents. The facility has emergency food and emergency to go backpacks for residents in care. There are no firearms or ammunition in the facility. 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. Facility has a wide variety of food available for residents. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed.
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2026
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CANYON VIEW HOME
FACILITY NUMBER: 361881321
VISIT DATE: 07/16/2026
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Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a wide variety of food available for residents. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed.

Yards/Outside: LPA observed the patio with plenty of tables, chairs and umbrellas for the residents in care. The backyard has a side gates with self-latching handle on the left and right side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Record Review: LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. LPA reviewed three (3) residents files for admissions agreements, pre-admissions appraisals, physician's reports, and care plans. LPA observed that all files were current and appeared to be maintained. No discrepancies. LPA review the facility files for LIC 500 (Staff Roster) LIC 9020 (Residents Roster), Emergency Disaster Plan, LIC 9282 (Infection Control Plan Annual Report), and Fire Drill. LPA observed the file were maintained and no discrepancies found. LPA conducted a medication audit for three (3) residents. Two (2) out of three (3) residents had medications that were on the MARs but not on the Centrally Stored Medication Sheet. A Deficiency cited.

Based on the observations made during today’s visit, two 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) and appear rights were discussed and provided to House Manager, Sandy Barr at the end of the visit.

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/16/2026 03:42 PM - It Cannot Be Edited


Created By: Lavette Farlow On 07/16/2026 at 03:15 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: CANYON VIEW HOME
FACILITY NUMBER: 361881321

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 observation and interview, the licensee did not comply with the section cited above by not ensuring that all disinfectant, and cleaning solutions were secured and inaccessible to residents in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2026
Plan of Correction
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The Administrator agreed to submit a statement of understanding acknowledging the regulation cited, and will conduct a training on the important of locking and securing all disinfectants, cleaning solutions etc.
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, and record review, the licensee did not comply with the section cited above in two (2) out of three (3) residents in care by not maintaining the centrally stored medication log with the residents MARs to ensure that all medication dispensed was logged which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2026
Plan of Correction
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The Administrator agreed to submit a statement of understanding acknowledging the regulation cited, and will conduct a training on the important of maintaining centrally stored medication log and common medication errors.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2026


LIC809 (FAS) - (06/04)
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