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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425610
Report Date: 03/28/2025
Date Signed: 03/28/2025 02:11:42 PM

Document Has Been Signed on 03/28/2025 02:11 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:EXCELCAREFACILITY NUMBER:
366425610
ADMINISTRATOR/
DIRECTOR:		ANDERSON, DORRISFACILITY TYPE:
740
ADDRESS:11400 POPLAR STREETTELEPHONE:
(909) 796-4553
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY: 10CENSUS: 5DATE:
03/28/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator Dorris AndersonTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to conduct a Health and Safety check. LPA met with Administrator Dorris Anderson, and discussed the purpose of the visit.

LPA toured the facility and observed dead roaches in Resident #3 (R3) bedroom, the dead roaches were on roach strips on top of R3’s dresser. LPA asked R3 if they have roaches often, R3 informed LPA yes, they have roaches and the Administrator has a guy that comes to the facility to spray and inspect the interior and exterior once a month. LPA asked R1 if the facility has roaches and R1 also informed LPA that yes, the facility has roaches. R1 has seen one in their room, however R1 stated R3’s room has it worse with roaches. R4 informed LPA they do not have roaches in their room, nor have they seen any throughout the house. LPA overheard Administrator scheduling an inspector to come out to the facility on Monday 3/31/25 to spray.

As LPA conducted interviews it was mentioned the facility does not provide activities for residents. LPA asked Administrator if activities are provided to residents and LPA was informed residents participate in activities at innovage three times a week. Therefore, no activities are not being provided to residents at the facility.

Based on observation deficiencies were cited per Title 22, Division 6 of The California Code of Regulations.



An exit interview was conducted where the Licensing reports were discussed and copies of the reports with Appeal Rights was provided to Administrator Dorris Anderson.
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Sarina Ramirez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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 03/28/2025 02:11 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Sarina Ramirez On 03/28/2025 at 01:39 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: EXCELCARE
FACILITY NUMBER: 366425610

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
03/29/2025
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times...
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Licensee has scheduled an inspector to come to the facility and spray the entire faciliy, an invoice will be provided to LPA upon visit.
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Based on observation and interviews, the licensee did not ensure the facility to be kept clean, safe, and sanitary which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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Under Appeal
Type B
03/31/2025
Section Cited
CCR87219(a)

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87219 Planned Activities
(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities..
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Licensee has agreed to create and follow the updated planned activite created for residents. An updated activities schedule will be sumitted to LPA by POC due date.
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Based on observation and interviews, the licensee did not ensure the facility to participate in planned activities which poses a potential Health, Safety, or Personal Rights risk to persons 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:
Sarina Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2025


LIC809 (FAS) - (06/04)
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