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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530291
Report Date: 07/10/2026
Date Signed: 07/10/2026 04:38:49 PM

Document Has Been Signed on 07/10/2026 04:38 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:MOONSTONE CARE HOMEFACILITY NUMBER:
365530291
ADMINISTRATOR/
DIRECTOR:		LOPEZ, ARMINDAFACILITY TYPE:
740
ADDRESS:950 S WILLOW AVENUETELEPHONE:
(619) 398-5169
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 6CENSUS: 6DATE:
07/10/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Clarita Navab, House Manager, Arminda Lopez, Licensee TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) LaVette Farlow, arrived at Moonstone Care Home, to conduct an unannounced comprehensive annual inspection. LPA was greeted and granted entry by House Manager Clarita Navab. LPA introduced self and stated purpose of the visit. Clarita informed Licensee Arminda Lopez, of LPA's arrival. During the course of the visit LPA completed a tour the facility inside and outside and observed the following:

Physical Plant: Facility is a one story house with five residents bedroom, one staff bedroom, two bathrooms, living room, family room, dining area, kitchen, pantry, laundry area, backyard and an attached two car garage. 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, chair, storage space, and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. LPA observed that facility has a sufficient supply of hygiene items for residents in care. Water temperatures tested at 119.9 and 117.5 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms and charged fire extinguisher which were tested 4/6/2026. LPA observed poster on display for personal rights, and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept in secure cabinets, inaccessible to residents. There was a designated storage space for client/staff files. Medications and first aid kit were in secure cabinets and inaccessible to clients. There are no firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions.

Food Service: LPA observed that the facility has a sufficient supply of perishable and non-perishable items. The facility has sufficient supply of dishes, cups, and utensils were also stored properly. Emergency food and water were observed.
(See LIC809C)
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2026
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: MOONSTONE CARE HOME
FACILITY NUMBER: 365530291
VISIT DATE: 07/10/2026
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Yards/Outside: LPA observed one shaded patio, a side gate 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 Administrator and 2 staff files for First Aid/CPR certification, criminal record clearance, training, health screenings and TB test. LPA reviewed 3 residents files for admissions agreements, pre-admissions appraisals, physician's reports, and care plans. Personnel records and residents file appeared to be complete and in order. LPA conduct an Audit of the residents MARs for three (3) out of three (3) residents in care. During the audit the facility received a package from Amazon with a bottle of Vitamin B Complex, that was ordered by the residents family to issue to the resident. LPA advised the facility to verify with the doctors that this vitamin is prescribed and authorized to be given with other medication being issued. A Technical Advisory issued.

LPA conducted an audit of facility records, for LIC610E, Emergency Disaster Plan, LIC9282, Infection Control Plan, Liability Insurance, and Fire Drills. Based on LPA observation and document review the facility folder appears to be maintained.

During today's visit no deficiency was cited one technical advisory issued per Title 22, Chapter 6 of the California Code of Regulation. An exit interview was conducted where this report LIC809, and LIC809C, was discussed and copies were provided to Licensee, Arminda Lopez.

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

DATE: 07/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2026
LIC809 (FAS) - (06/04)
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