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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530214
Report Date: 10/21/2025
Date Signed: 10/21/2025 11:22:59 AM

Document Has Been Signed on 10/21/2025 11:22 AM - 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:RHE AVA HOME CAREFACILITY NUMBER:
365530214
ADMINISTRATOR/
DIRECTOR:		GARCIA, CRISZELIEFACILITY TYPE:
735
ADDRESS:16005 AVA PLACETELEPHONE:
(909) 347-7133
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 4CENSUS: 4DATE:
10/21/2025
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Administrator Criszelie De La Cruz GarciaTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 10/21/2025, Licensing Program Analyst (LPA) Beena Singh made an unannounced visit to the facility. The purpose of the visit was to conduct a post licensing inspection. LPA met with a staff and and were granted entry to the facility. Administrator Criszelie De La Cruz Garcia was been contacted, arrived during the visit and informed the purpose of the visit.

The facility is an Adult Residential Facility (ARF) level 4g designated home vendor by Inland Regional Center. Licensed capacity is (4) current census (4). LPA Singh observed one(1) client at the facility. Facility administrator Criszelie De La Cruz Garcia informed that three(3) clients are at the day-program. LPA was accompanied by Administrator Criszelie De La Cruz Garcia to conduct a general overall inspection, which included, but was not limited to, the following:

Facility is a one (1) story house with four (4) client bedrooms, three (3) bathrooms, living room, dining room, and kitchen. There was an attached two (2) car garage on the left side of the house. Central heating and air conditioning system installed with one (1) central panel located in the hallway to control entire house.

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. Outdoor activity space is shaded and enclosed with a self-latching gate. The facility is maintained at a comfortable temperature of 72 degrees Fahrenheit.

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Beena Singh
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2025
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: RHE AVA HOME CARE
FACILITY NUMBER: 365530214
VISIT DATE: 10/21/2025
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Bedrooms/Bathroom: Each client bedrooms accommodate any ambulatory client. All client bedrooms were adequately furnished with bed, chair, closet, appropriate linen, adequate lighting, a lamp and an operable smoke/carbon monoxide alarm. The three (3) bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap. LPA tested the water temperatures in the clients' bathroom. LPA Singh verified water temperature was measured at 107 degrees Fahrenheit.

Food Service: The facility has more than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food for clients in care.

An adequate supply of dishes, glasses, utensils, pots, and pans were observed in the kitchen cabinets. Knives/sharp instruments were secured in a locked cabinet located in the file room/laundry room. There was adequate room for food storage. LPA Singh observed the stove to be operational. Refrigerator/freezer were in working condition. There is sufficient storage for perishable food. There was adequate seating for meals for all clients.

Laundry: Laundry room with washer and dryer was in the laundry room. Laundry detergents and cleaning supplies were observed in a locked cabinet. Garage door is locked away from clients.

Living/Family room:

There was a living/family room with adequate seating for all clients and a working TV.

Linens and Hygiene Supplies:

An adequate supply of linens was stored in a cabinet in the hallway of the residence.

Yards/Outside: Patio furniture for outdoor seating observed. Self-latching handle gate on left side of the house leads into the backyard. All outdoor pathways were free of obstructions.

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Beena Singh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: RHE AVA HOME CARE
FACILITY NUMBER: 365530214
VISIT DATE: 10/21/2025
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Health Related Services: Staff maintain client medication records and medications are centrally stored in a locked cabinet.

Facility sketches were observed posted near the main entrance. There was Let-Us-No poster, emergency disaster, personal rights, and Labor Laws observed. One (1) fire extinguisher was charged and located in the kitchen/dining area. Two (2) combined smoke detectors and carbon monoxide detectors were tested and were observed to be in working order. Client records and staff records are stored in a locked cabinet next to laundry area. First Aid kit with required components, and locked area for medication storage was observed. There is enough Emergency water supply and the required 72-hour emergency food supply for clients and staffs available at the facility, stored in the garage.

Additionally, LPA Singh observed facility having Visitor Sign In/Sign Out Sheet and Client Sign In/Sign Out Sheet, upon entering facility. The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22, Division 6, Chapters 1 and 6 to ensure the health and safety of clients in care.

Record Review: Two (2) client files were reviewed for admission agreements, physician's reports, appraisals, P&I records, needs and services plans. Two (2) staff files were reviewed Crisis prevention interventions and First Aid/CPR certifications, criminal record clearances, personal record/history, training and health screenings. The facility maintains a surety bond effective dates-03/15/2024-02/12/2027, Liability insurance- effective dates from 02/01/2025 to 01/02/2026, infection control plan, and disaster/emergency plan for review. Fire drill conducted on 09/10/2025 and earthquake drill on 09/17/2025.

Based on the observations made during today's visit, no deficiency were cited per Title 22 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report, LIC809 was discussed and provided to Applicant/Administrator Criszelie De La Cruz Garcia.

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Beena Singh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4