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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408353
Report Date: 08/21/2025
Date Signed: 08/21/2025 12:08:46 PM

Document Has Been Signed on 08/21/2025 12:08 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:JP'S RESIDENTIAL CAREFACILITY NUMBER:
366408353
ADMINISTRATOR/
DIRECTOR:		PIERRE, YVONNEFACILITY TYPE:
735
ADDRESS:922 W. MESA DRIVETELEPHONE:
(909) 875-6147
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 2CENSUS: 1DATE:
08/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Yvonne Pierre, LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On 08/21/2025, Licensing Program Analysts (LPA) LaVette Farlow arrived unannounced to conduct the required comprehensive annual inspection to the facility. LPA Farlow met with Licensee/Administrator Yvonne Pierre and introduced myself and stated purpose of the visit.

The facility has five (5) bedrooms, three (3) bathrooms, kitchen, dining area, living room, family room, backyard, and attached garage. LPA Farlow completed a walk through of facility, review of records, medication audit.

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. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. LPA Farlow inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA Farlow inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 111.2 degrees Fahrenheit. During the tour LPA observed the facility is equipped with smoke detectors, carbon monoxide alarms, charged fire extinguisher and first aid kit with First Aid book. However, the smoke detector/carbon monoxide alarms needed batteries. Licensee immediately replaced the batteries, and was able to conduct the required testing. A deficiency was cited. There was a designated storage space for client/staff files. Client medications was observed locked and inaccessible to client. There is no firearms, ammunition, swimming pool or bodies of water in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.
***Continuation LIC 809C***
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2025
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: JP'S RESIDENTIAL CARE
FACILITY NUMBER: 366408353
VISIT DATE: 08/21/2025
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Posters such as; the personal rights, facility license were posted in a common area. However, LPA observed that the facility CCLD Complaint Poster, personal rights were in the common area, but was covered by other picture frame or not easily accessible to view. A deficiency was cited.

Food Service: Non-perishable and perishable food supply is sufficient. Facility has a wide variety of food available. Dishes, cups, and utensils were also stored properly

Yards/Outside: Side gate with self-latching handle on the left 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.

Record Review: LPA observed that Licensee did not develop the required Infection Control Plan. Deficiency will be issued. In addition, LPA reviewed administrator files for First Aid/CPR certification, criminal record clearance, training's, and health screenings, tuberculosis (TB) test with TB test result. LPA observed that files reviewed were complete. LPA reviewed one (1) client files for admission agreements, updated physician reports/medical assessment, Individual Program Plan (IPP) and centrally stored medication list. LPA observed the Licensee did not have the current IPP report. The Licensee did email Inland Regional Center requesting updated report. A technical violation was issued. .

Client #1 (C1) medications was audited and LPAs observed no issue.. LPA reviewed facility's file for fire drills, and emergency disaster plan. LPA observed the Licensee did not have a current LIC610D. A technical violation issued.

During todays visit two deficiencies were cited and two technical violation were issued per Title 22, Division 6 of California Code of Regulation (CCR). An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102 and Appeal Rights were discussed and copies were provided to Yvonne Pierre, Licensee/Administrator. Licensee refused to sign the last page of the LIC809D for citation 85095.5.

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

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/21/2025 12:08 PM - It Cannot Be Edited


Created By: Lavette Farlow On 08/21/2025 at 11:26 AM
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: JP'S RESIDENTIAL CARE
FACILITY NUMBER: 366408353

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

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 ensuring the smoke detector/carbon monoxide alarm, was operational and have batteries in place to ensure activation and properly working alarms, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2025
Plan of Correction
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Licensee immediately place batteries in the smoke detector/carbon monoxide alarm for proper testing. Licensee agrees to maintain batteries, and to continue conducting routine drills.
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.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/21/2025 12:08 PM - It Cannot Be Edited


Created By: Lavette Farlow On 08/21/2025 at 11:26 AM
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: JP'S RESIDENTIAL CARE
FACILITY NUMBER: 366408353

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(a)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows:

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 having in place an Infection control plan for review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/11/2025
Plan of Correction
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Licensee agrees to create an Infection Control and maintain a folder for the Infection Control to be reviewed by CCL upon request. The Licensee will submit a photo, email, fax, or mail the document to CCLD by POC to LPA Farlow.
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.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2025


LIC809 (FAS) - (06/04)
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