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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530326
Report Date: 05/21/2026
Date Signed: 05/21/2026 03:58:42 PM

Document Has Been Signed on 05/21/2026 03:58 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:FISHER MANOR 1FACILITY NUMBER:
365530326
ADMINISTRATOR/
DIRECTOR:		QASIM, AHMEDFACILITY TYPE:
740
ADDRESS:25243 FISHER STTELEPHONE:
(909) 885-3330
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92404
CAPACITY: 15CENSUS: 11DATE:
05/21/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:10 PM
MET WITH:Caregiver, Elizabeth HernandezTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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On 05/21/2026 at 3:10PM Licensing Program Analyst (LPA) Renese Howell-Small conducted a case management visit at the facility. LPA met with caregiver, Elizabeth Hernandez and completed a tour of the facility.

LPA observed two (2) black rugs in the residents' shared bathroom that did not have non-slip material underneath. A deficiency will be cited. LPA also requested access to review both staff and resident files, but was unable review files. The Administrator was contacted via telephone and informed that staff did not have the key to access the files. The Administrator was unable to provide the key for access during the visit. A deficiency will be cited.

An exit interview was conducted where this report LIC809, LIC809D and Appeal Rights were discussed and copies were provided to caregiver, Elizabeth Hernandez.
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Renese Howell-Small
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2026
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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Document Has Been Signed on 05/21/2026 03:58 PM - It Cannot Be Edited


Created By: Renese Howell-Small On 05/21/2026 at 03:21 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: FISHER MANOR 1
FACILITY NUMBER: 365530326

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/22/2026
Section Cited
CCR
87307(3)(A)

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87307 Personal Accommodations and Services (3) All persons shall be protected against hazards...through provision of the following:
(A) Protective devices such as nonslip material on rugs. This requirement was not met as evidenced by:
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The Licensee/Adminstrator will remove the rugs and/or provide rugs that have non-slip material and submit proof to LPA by Plan of Correction (POC) due date.
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Based on observation, the Licensee/Administrator did not ensure that the black rugs for the toilet and shower/bathtub in the residents's shared bathroom had non-slip material which posed an immediate risk to the health and safety of residents in care.
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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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Renese Howell-Small
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/21/2026 03:58 PM - It Cannot Be Edited


Created By: Renese Howell-Small On 05/21/2026 at 03:37 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: FISHER MANOR 1
FACILITY NUMBER: 365530326

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/25/2026
Section Cited
CCR
87412

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87412 Personnel Records (f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.

This requirement was not met as evidenced by:
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The Licensee/Administrator will provide a key or other type of access to staff and submit a statement along with proof of how staff have access to resident files by Plan of Correction (POC) due date.
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Based on observation and interview, the Licensee/Administrator did not ensure that staff had a key or access to staff files, which posed a potential risk to the health and safety of residents in care.
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Type B
05/25/2026
Section Cited
CCR87506(d)

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(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.

This requirement was not met as evidenced by:
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The Licensee/Administrator will provide a key or other type of access to staff and submit a statement along with proof of how staff have access to resident files by Plan of Correction (POC) due date.
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Based on observation and interview, the Licensee/Administrator did not ensure that staff had a key or access to resident files, which posed a potential risk to the health and safety of residents in care.
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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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Renese Howell-Small
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2026


LIC809 (FAS) - (06/04)
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