366424158-5-12-2026-56-AS-ECOS-DTZQME-20260512121724

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366424158
Report Date: 05/12/2026
Date Signed: 05/12/2026 12:20:08 PM

Document Has Been Signed on 05/12/2026 12:20 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:	YUCAIPA VALLEY BOARD & CARE		FACILITY NUMBER:	366424158
ADMINISTRATOR/ DIRECTOR:	ANIKO A. BARLOW		FACILITY TYPE:	740
ADDRESS:	33176 COLORADO STREET		TELEPHONE:	(909) 795-3065
CITY:	YUCAIPA	STATE: CA	ZIP CODE:	92399
CAPACITY: 5		CENSUS: 4	DATE:	05/12/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Aniko Barlow, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:25 PM

NARRATIVE

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Licensing Program Analyst (LPA) E. Conchas made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Administrator Aniko Barlow and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE) with a licensed capacity of five (5) and a current census of four (4) residents in care. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Indoor passageways were free of obstruction. The outdoor shaded area was sufficient for resident activities and enclosed with a self-latching gate. The facility had adequate lighting and was maintained at a comfortable temperature.

Residents’ showers, toilets, and hand washing areas were observed to be in safe and sanitary operating condition. The hot water temperature in residents’ bathroom measured 105.4°F. Residents’ bedrooms contained the required furniture and furnishings. The facility had operating carbon monoxide and smoke alarms, laundry equipment, and telephone service. Sufficient bed linens, towels, and personal hygiene items were available for residents.

The facility had the Community Care Licensing complaint poster, Ombudsman poster, and facility license posted in a common area. Sharps, disinfectants, and cleaning solutions were kept locked in a cabinet. The facility has staff onsite 24 hours a day, 7 days a week. Staff had current CPR/First Aid certifications.

Continue to LIC 809-C.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Edith Conchas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

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: YUCAIPA VALLEY BOARD & CARE	FACILITY NUMBER: 366424158
	VISIT DATE: 05/12/2026

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Residents’ medications were properly labeled and centrally stored in a locked cabinet. The facility maintained a complete first aid kit with a manual. The kitchen and dining areas were clean. The facility maintained a sufficient supply of perishable and non- perishable food items for residents. A menu was posted in the kitchen area.

Staff file was reviewed. Resident files were reviewed and found to be complete. The facility has current liability insurance, an emergency disaster plan, and an infection control plan available for review.

Based on observations and record review, the following deficiencies are being cited per Title 22 of the California Code of Regulations and the Health and Safety Code:

• The licensee did not have the required 20" x 24" complaint poster displayed. A Technical Advisory was issued.

• The licensee did not maintain an supply of good quality food items in the overstock pantry. A Technical Advisory was issued.

• The licensee did not maintain current annual training for staff for the year 2026. A deficiency was cited.

This report and LIC 809-D were reviewed with the Administrator. A copy of the report, along with Appeal Rights, was provided to the Administrator at the conclusion of the visit.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Edith Conchas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/12/2026 12:20 PM - It Cannot Be Edited

Created By: Edith Conchas On 05/12/2026 at 11:54 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: YUCAIPA VALLEY BOARD & CARE	FACILITY NUMBER: 366424158
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 completing January - April annual training with staff which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/09/2026
	Plan of Correction
1 2 3 4	Licensee shall conduct the annual training that is four months overdue and ensure ongoing completion of staff annual trainings. The licensee shall submit a copy of the completed training, along with the email subject line, by the POC date

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

	Edith Conchas
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/12/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

LIC809 (FAS) - (06/04)

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