365530012-1-8-2026-56-AS-LFAW-DQ6475-20260108175035

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 365530012
Report Date: 01/08/2026
Date Signed: 01/08/2026 05:50:44 PM

Document Has Been Signed on 01/08/2026 05:50 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:	HELPING HEARTS ACACIA		FACILITY NUMBER:	365530012
ADMINISTRATOR/ DIRECTOR:	HAMPTON, CHRISTAL		FACILITY TYPE:	772
ADDRESS:	1767 N ACACIA AVE		TELEPHONE:	(909) 292-8997
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY: 6		CENSUS: 6	DATE:	01/08/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:35 PM
MET WITH:	Lori Secord, Program Director		TIME VISIT/ INSPECTION COMPLETED:	05:55 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst, LaVette Farlow, (LPA) arrived at the Helping Hearts: Acacia Social Rehabilitation Facility, to conduct the Annual Inspection. LPA was granted entry by Program Director, Lori Secord. LPA introduced self to Program Director, Lori Secord and stated the purpose of the visit. Lori escort LPA to her office and provided a space to work and a walk through of the facility. LPA was accompanied by Program Director, Lori Secord to conduct a tour of the facility, inside and outside, and observed the following: Facility: The Facility is licensed for six (6) ambulatory adults, ages 18 -59. Physical Plant: LPA observed the facility was maintain within a reasonable temperature, of 73 degrees. Interior pathways were free of clutter. Resident rooms contained beds with appropriate linens, adequate amounts of storage space, night stands, sufficient lighting, seating and privacy. Bathrooms contained operational appliances adequate amount of hand hygiene and paper supplies. Also, non-slip grip materials for safety. Extra hygiene and paper good supplies are securely maintained. LPA measured the water temperature in the facility's bathrooms, and kitchen. Water temperature ranged between 116.6, and 112.9 degrees Fahrenheit. Sufficient lighting is provided throughout the facility with various lamps and night lights. The facility contained smoke/fire/carbon monoxide alarms. Program Director reports that Earthquake and Fire Drills are conducted on a monthly basis. LPA observed two fully charged fire extinguishers throughout the facility; last inspected March 20, 2025. *LIC809 continued*

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026

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: HELPING HEARTS ACACIA	FACILITY NUMBER: 365530012
	VISIT DATE: 01/08/2026

NARRATIVE

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Food Service: During the walk through of the kitchen, LPA observed the facility's non-perishable and perishable food supply. The facility has a sufficient amount of canned and dry goods in good standing. Perishable foods are maintained within 2 refrigerators and 3 freezers. LPA observed a variety of food items available to residents in care. Items such as frozen meals, beverages, eggs, vegetables, milk, and meats. Food Menu observed posted near the kitchen.

Care & Supervision: During today's visit, it was reported the current census is six (6), with (3) staff members present including Program Director which is adequate for the number of residents in care. The facility maintain a sufficient number of staff for clients in care.

Record Review and Resident/Staff Files: LPA reviewed records for updated physician reports and Needs and Services Plans. LPA verified resident records contained required documents. LPA observed that two (2) out of three (3) clients files was missing a current physician report. A technical violation issued. LPA reviewed staff files; and confirmed that staff records reflect current CPR/First Aid Certification and Criminal Record Clearance, Health Screening, TB test, and Training records.

Administration: Facility Sketch, Disaster Plan, Emergency Contact Information & Procedures, Fire Inspection letter, Ombudsman poster, Resident Rights, House Rules, Infection Control, and facility license are posted in a prominent place in the facility.

Medication/Medical Related Services: LPA observed that the residents' medication is centrally stored and securely maintained.

Based on observations, record reviews and interviews, no deficiencies were cited during this inspection. One technical violation issued. Exit interview conducted, this report was reviewed, discussed and copy provided to Program Manager, Lori Secord.

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026

LIC809 (FAS) - (06/04)

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