366425506-1-6-2026-56-AS-ECOS-DQ3SWQ-20260106131444

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366425506
Report Date: 01/06/2026
Date Signed: 01/06/2026 01:15:09 PM

Document Has Been Signed on 01/06/2026 01:15 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 ADULT DAY CENTER		FACILITY NUMBER:	366425506
ADMINISTRATOR/ DIRECTOR:	MURRAY, SHARAN		FACILITY TYPE:	775
ADDRESS:	12980 2ND STREET		TELEPHONE:	(909) 790-4012
CITY:	YUCAIPA	STATE: CA	ZIP CODE:	92399
CAPACITY: 49		CENSUS: 42	DATE:	01/06/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Administrator, Vernon Marasigan		TIME VISIT/ INSPECTION COMPLETED:	01:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) E.Conchas conducted an unannounced visit to the facility for an annual inspection. LPA met with the facility administrator, Vernon Marasigan. The facility is a licensed vendor of the Inland Regional Center. LPA toured the facility inside and out and walkways/hallways. The facility is a one- story building consisting of one large community room that is shared by clients. At the time of the visit, LPA observed clients participating in activities and listening to music. The facility contains one office, one staff break room, two restrooms, a laundry room, a kitchen area, main activity room, the nurses room and a changing room. The facility has no bodies of water. The facility has five (5) charged fire extinguishers serviced on 10/22/2025. Fire inspection was completed on 11/25/2025. Outdoor and indoor passageways were kept free of obstruction. The outside of the facility had a seating area. Cleaning supplies, and sharps were kept locked and inaccessible to the clients. Centrally stored medications were kept in a safe and locked area in the nurses office. LPA toured the kitchen. Clients bring their own lunches and snacks are provided to clients during program hours. LPA observed perishable and non-perishable food stored in a safe and healthful manner. Facility has an emergency food supply and was observed to expire in 2038. The facility had a complete first aid kit and the last disaster drill was conducted on 10/16/2025. LPA toured the client bathrooms. The bathrooms were operating in a sanitary condition. LPA measured the hot water temperature in the bathroom at 130 degrees F in the females restroom. A deficiency was cited. Continue LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Edith Conchas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026

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 01/06/2026 01:15 PM - It Cannot Be Edited

Created By: Edith Conchas On 01/06/2026 at 12:38 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: YUCAIPA ADULT DAY CENTER	FACILITY NUMBER: 366425506
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

82088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2026
	Plan of Correction
1 2 3 4	Place a work order to correct water temperature and administrator will send work completion with an updated verfied water temperature is measured based on regualtion cited.

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: 01/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026

LIC809 (FAS) - (06/04)

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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 ADULT DAY CENTER	FACILITY NUMBER: 366425506
	VISIT DATE: 01/06/2026

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LPA reviewed staff and client files. Staff files had most required documentation including a health screening report, training and current first aid/CPR certification. A Technical advisory was issued. Client files had the required documentation including an admission's agreement updated IPP's and physical health report. LPA reviewed medications. Medications were dispensed appropriately according to the physician's orders.

An exit interview was conducted where this report was discussed and provided to the facility manager.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Edith Conchas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026

LIC809 (FAS) - (06/04)

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