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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530192
Report Date: 05/15/2026
Date Signed: 05/15/2026 02:23:07 PM

Document Has Been Signed on 05/15/2026 02:23 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:DOS PALMAS RESIDENTIAL CAREFACILITY NUMBER:
365530192
ADMINISTRATOR/
DIRECTOR:		CONSTANCE ODUDUFACILITY TYPE:
735
ADDRESS:13160 DOS PALMAS RD.TELEPHONE:
(909) 251-3437
CITY:VICTORIVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: 4DATE:
05/15/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:02 AM
MET WITH:David Adubi- LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:43 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Staff, Hailyn Martinez and introduced self and stated purpose of the visit. Staff, Samuel Adubi and Licensee, David Adubi arrived shortly after to assist with the inspection.

The facility has four (4) bedrooms, two (2) bathrooms, living room, family room, kitchen, dining area, laundry room, one attached car garage used as an office, attached 2 car garage, back yard with shed. LPA completed a walk through of facility, review of records, medication and P&I audit. LPA toured the interior and exterior areas of the facility.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). The facility is vendorized by Inland Regional Center. The facility is maintained at a comfortable temperature of 74 degrees Fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and some lighting. LPA observed bedroom #2 and bedroom #4 lights not properly working and need to be replaced. Deficiency issued. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 99 degrees Fahrenheit. LPA observed that the water temperature in the bathroom faucet did not measure within regulation. Deficiency issued. The facility is equipped with operational smoke detectors, carbon monoxide alarms, first aid kit, emergency kits and fire extinguisher. Posters such as; the personal rights, CCL complaint poster, house rules emergency disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inside a locked closet made inaccessible to clients. There was a designated storage space for client/staff files. Medications was observed inside locked cabinets and inaccessible to clients in care. LPA observed the following issues: bedroom #1 closet doors are out of place and needs to be repaired, exposed wiring found on the kitchen's outlet next to the house phone that needs to be repaired and the carbon monoxide alarm on top of the refrigerator without a battery was not functioning since a month ago along with 2 fire extinguishers without proof of annual servicing.. Deficiency issued. LPA observed that the exit door in the garage is obstructed with an electric chair, table and boxes. Deficiency issued.
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Michelle Echeverria
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2026
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DOS PALMAS RESIDENTIAL CARE
FACILITY NUMBER: 365530192
VISIT DATE: 05/15/2026
NARRATIVE
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Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Dishes, cups, and utensils were also stored properly. LPA observed that staff 2 (S2) served heated canned ravioli and sliced apples to the clients during lunch time. LPA observed that S2 did not follow sanitation practices while preparing lunch. Deficiency issued. LPA observed that the menu for today was supposed to be peanut butter & jelly sandwich, and a 8oz beverage. Staff 1 (S1) stated that the facility did not have the ingredients stated on the menu. Deficiency issued.

Yards/Outside: One shaded patio, a side gate with self-latching handle on the right side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for 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 4 client files for admission agreements, updated physician reports, and needs and services plans. LPA observed that 3 clients did not have an updated IPP since 2024. Deficiency issued. LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed that the client's P&I ledger were not updated since March 2026. LPA was not able to audit the currency due to records not updated and receipts not provided. Deficiency issued. LPA observed during record review that two clients did not have record of the times that their PRN medication was administered by staff. Deficiency issued. LPA reviewed the facility's liability insurance, surety bond, emergency disaster plan, infection control plan and emergency drills.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D and appeal rights were discussed and copies were provided to the Licensee, David Adubi.

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Michelle Echeverria
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/15/2026 02:23 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 05/15/2026 at 01:15 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: DOS PALMAS RESIDENTIAL CARE
FACILITY NUMBER: 365530192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80026(h)
Safeguards for Cash Resources, Personal Property and Valuables
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not updating the client's P&I ledgers since March 2026 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2026
Plan of Correction
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Licensee stated that he submit a statement of understanding on the regulation cited and send proof to LPA via email by POC due date.
Section Cited
Deficient Practice Statement
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4
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.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Michelle Echeverria
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/15/2026 02:23 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 05/15/2026 at 01:15 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: DOS PALMAS RESIDENTIAL CARE
FACILITY NUMBER: 365530192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 having following issues: bedroom #1 closet doors are out of place and need to be repaired, exposed wiring found in the kitchen's outlet next to the house phone that needs to be repaired, 2 fire extinguishers have no proof of annual servicing and the carbon monoxide alarm was not functioning on top of the refrigerator without a battery since a month ago which poses posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2026
Plan of Correction
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Licensee stated that he will fix the closet door in bedroom #1, repair the kitchen's outlet and place the carbon monoxide in an area where it will not be knocked down. Licensee will submit proof of corrections with pictures sent to LPA via email by POC due date.
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

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 clearing the garage side exit door which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2026
Plan of Correction
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Licensee stated that he will clear the side exit path of the garage and send proof to LPA via email by 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.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Michelle Echeverria
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/15/2026 02:23 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 05/15/2026 at 01:15 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: DOS PALMAS RESIDENTIAL CARE
FACILITY NUMBER: 365530192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(d)
Fixtures, Furniture, Equipment, and Supplies
(d) The licensee shall provide lamps or lights as necessary in all rooms and other areas to ensure the comfort and safety of all persons in the facility.

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 repairing on time bedroom #2 and bedroom #4 lights which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2026
Plan of Correction
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Licensee stated that the lights on bedroom #2 and #4 will be repaired and proof will be sent as pictures to LPA via email by POC due date.
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 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 maintaining the hot water in the bathrooms between 105-120 degrees Fahrenheit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2026
Plan of Correction
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Licensee stated that he will submit a plan on how staff will conduct daily water temperature checks. Licensee will submit proof to LPA via email by 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.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Michelle Echeverria
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2026


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 05/15/2026 02:23 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 05/15/2026 at 01:15 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: DOS PALMAS RESIDENTIAL CARE
FACILITY NUMBER: 365530192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above by not having 3 client's IPP updated since 2024 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2026
Plan of Correction
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2
3
4
Licensee stated that he will submit a statement of understanding on the regulation cited and send proof to LPA via email by POC due date.
Type B
Section Cited
CCR
80076(a)(1)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan -Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and interview, the licensee did not comply with the section cited above by staff not serving a lunch meal with at least 1/3 of the servings recommended in the USDA Basic Food Group Plan- Daily Food Guide which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2026
Plan of Correction
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2
3
4
Licensee stated that he will conduct training with all staff on the regulation cited and submit proof to LPA via email by 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.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Michelle Echeverria
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2026


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 05/15/2026 02:23 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 05/15/2026 at 01:15 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: DOS PALMAS RESIDENTIAL CARE
FACILITY NUMBER: 365530192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(13)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (13) All persons engaged in food preparation and service shall observe personal hygiene and food services sanitation practices which protect the food from contamination.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by staff 2 (S2) not practicing food services sanitation procedures which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2026
Plan of Correction
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2
3
4
Licensee stated that all staff will be trained on the regulation cited and proof will be sent to LPA via email by POC due date.
Type B
Section Cited
CCR
80075(b)(5)(C)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (C) A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the client's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not having a record available for audit for two client's PRN medication administration which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2026
Plan of Correction
1
2
3
4
Licensee stated that he will submit a statement of understanding on the regulation cited and send proof to LPA via email by 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.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Michelle Echeverria
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2026


LIC809 (FAS) - (06/04)
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