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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530047
Report Date: 01/23/2025
Date Signed: 01/23/2025 01:58:22 PM

Document Has Been Signed on 01/23/2025 01:58 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:BANYAN HOUSEFACILITY NUMBER:
365530047
ADMINISTRATOR/
DIRECTOR:		ESTELLE, VICKIFACILITY TYPE:
735
ADDRESS:18326 BANYAN AVETELEPHONE:
9095872431
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY: 6CENSUS: 2DATE:
01/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:52 AM
MET WITH:Leslie Hodges, CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst, LaVette Farlow, (LPA) arrived at the Banyan House, Adult Residential Facility unannounced to conduct an Annual Inspection. LPA introduced self and stated purpose of the visit. LPA met with Staff Members, Leslie Hodges and Gina Moya who granted LPA entry inside facility. Staff contacted Administrator, Vicki Estelle, who arrived later during the visit.

LPA was accompanied by Staff Member, Leslie to conduct a tour of the facility, inside and outside, and observed the following:

Facility: The Facility is approved for six (6) ambulatory adults, ages 18 -59. The current census is two (2). LPA observed that the facility is operating in the capacity and conditions approved by Community Care Licensing (CCL).

Physical Plant: LPA observed the facility to be maintained at a comfortable temperature. Interior and exterior pathways were free of clutter and obstructions. LPA tested the facility water and the temperature tested at 106.3 and 105.2 degrees. LPA observed 5 bedrooms and 2 bathrooms. Two bedroom currently houses 2 residents in care and 1 is for staff. The other two rooms are vacant. Resident rooms each included appropriate lighting, seating, bed and linens and storage for residents in care. Various light sources such as lamps and night-lights were observed throughout the facility. Each bathroom included operable appliances, adequate amounts paper supplies, non-slip materials and handrails. LPA observed hygiene supplies, personal and linens are kept secure in hallway closets. LPA observed the facility did not have sufficient supply of toothpaste and conditioner for residents in care. Technical violation issued. Additionally, LPA observed chemicals, tools and resident medications were also kept secure in a hallway closet. Fire extinguishers, (2) were observed fully charged and last inspected September 11, 2024. LPA was informed the facility conducts fire and earthquake drills regularly. LPA found the records for the facility drill were not consistently documented. Last drill conducted 1/2025 and prior drills were 7/2024, and 2023. Technical violation issued. LPA observed a shed in the backyard and it was locked and secured. Licensee/staff did not have access to enter the shed. A deficiency was cited.
Please see LIC809-C
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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 8
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: BANYAN HOUSE
FACILITY NUMBER: 365530047
VISIT DATE: 01/23/2025
NARRATIVE
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Food Service: LPA observed the facility's kitchen. LPA was shown the non-perishable food supply was sufficient in amounts and in good standing. LPA observed the facility's refrigerators and freezers to include food items such as milk, bread, fresh fruits and vegetable and beverages also sufficient in amounts for the number of residents in care. LPA observed the facility was not equipped with emergency food supply in case of evacuation. A deficiency was cited.

Care & Supervision: Facility has two staff members who resident on facility grounds which is adequate for the number of residents in care.
Record Review and Resident/Staff Files: LPA reviewed two (2) client files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed two (2) client medications which appeared to be administered as prescribed by their physician. P&I was reviewed and appeared to balance ledger. LPA reviewed, three, (3) staff files; and confirmed that staff records reflect current CPR/First Aid Certification and Criminal Record Clearance. The Administrator's Administrator Certificate in good standing. LPA observed one worker cleaning and fixing items on the grounds, this staff member has not been cleared. Licensee stated she did not know that she would need to be cleared if she does not interact with residents in care. A deficiency cited. LPA observed license did not have emergency to go bags for residents in care. Technical violation issued.
Administration: Facility Sketch/Disaster Plan, Emergency contact information, Ombudsman poster, Resident Rights, House Rules, Infection Control, Administrator Certificate, and facility license are posted in the hallway of the facility.
Medication/Medical Related Services: LPA observed that the residents' medication is centrally stored and secure in a hall closet. LPA reviewed the residents' medications list and compared it to the facility's Medication Administration Report (MARS). LPA observed several medication were not listed on the MARS a deficiency cited.

Based on observations, record reviews and interviews, deficiencies and technical violation were cited during this inspection. Deficiencies and Technical Violations are being issued to address the above mentioned concerns. Exit interview conducted, this report was reviewed, discussed and copy provided to Caregiver Leslie Hodges.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC809 (FAS) - (06/04)
Page: 8 of 8
Document Has Been Signed on 01/23/2025 01:58 PM - It Cannot Be Edited


Created By: Lavette Farlow On 01/23/2025 at 01:31 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: BANYAN HOUSE
FACILITY NUMBER: 365530047

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Lavette Farlow
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 01/23/2025 01:58 PM - It Cannot Be Edited


Created By: Lavette Farlow On 01/23/2025 at 01:32 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: BANYAN HOUSE
FACILITY NUMBER: 365530047

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80044


This requirement is not met as evidenced by: The licensing agency shall have the inspection authority specified in Health and Safety Code Sections 1526.5, 1533, 1534, 1538, and 1538.7.
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in by not granting LPA access to the shed in the backyard. The Licensee and staff stated the maintenance man was the only one with the key to the shed. The Licensee further stated the maintenance man was in Barstow. Denying LPA access to enter into the shed located in the backyard of the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/24/2025
Plan of Correction
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The Licensee agree to keep a key on the grounds at all time allowing access to CCL or any other authorized personnel.
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:Nedra Brown
LICENSING EVALUATOR NAME:Lavette Farlow
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 01/23/2025 01:58 PM - It Cannot Be Edited


Created By: Lavette Farlow On 01/23/2025 at 01:41 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: BANYAN HOUSE
FACILITY NUMBER: 365530047

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed 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 in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Type A
Section Cited
HSC
1565(a)(7)(E)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (7) Procedures that address, but are not limited to the following: (E) Storage and preservation of medications, including the storage of medications that require refrigeration.

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 in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
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.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Lavette Farlow
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 01/23/2025 01:58 PM - It Cannot Be Edited


Created By: Lavette Farlow On 01/23/2025 at 01:41 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: BANYAN HOUSE
FACILITY NUMBER: 365530047

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(f)(2)(D)
Other Provisions
(f) A facility shall have both of the following in place: (2) A set of keys available for use during an evacuation that provides access to all of the following: (D) All facility cabinets and cupboards or files that contain elements of the emergency and disaster plan, including, but not limited to, food supplies and protective shelter supplies.

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 in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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2
3
4
Section Cited
Deficient Practice Statement
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2
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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.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Lavette Farlow
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


LIC809 (FAS) - (06/04)
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