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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881399
Report Date: 06/30/2025
Date Signed: 06/30/2025 12:10:25 PM

Document Has Been Signed on 06/30/2025 12:10 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HOPE ARFFACILITY NUMBER:
371881399
ADMINISTRATOR/
DIRECTOR:		DOST, LEENAFACILITY TYPE:
735
ADDRESS:551 VIA DEL CABALLOTELEPHONE:
(760) 304-4631
CITY:SAN MARCOSSTATE: CAZIP CODE:
92078
CAPACITY: 4CENSUS: 3DATE:
06/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Khalid AbdallaTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit for a required annual inspection. The LPA was greeted by Caregiver Khalid Abdalla, notified them of the purpose for the visit and was allowed to enter the facility to conduct the inspection.

Facility Overview: The facility is a Two-story building with 3 clients' bedrooms, 2.5 bathrooms, a dinning room, 2 living rooms, a kitchen, an outdoor area, and a garage. There is no gated pool and there are no firearms on the premises.

Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance.

Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in the kitchen and inaccessible to clients. The smoke detector and carbon monoxide detector were operable. LPA observed fire extinguishers to be in compliance with the department's requirements and with an expiration date of 02-21-2026. The water temperature was tested within regulations measuring 117.3 F

Continued 809-C......

NAME OF LICENSING PROGRAM MANAGER: Rikesha Stamps
NAME OF LICENSING PROGRAM ANALYST: Abdoulaye Zerbo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2025
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HOPE ARF
FACILITY NUMBER: 371881399
VISIT DATE: 06/30/2025
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Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The Administrator holds a current administrator’s certificate with the expiration date of 08-10-2026


Record Review and Resident/Staff Files: The facility did not have staff files for LPA to review. A citation will be issued. 3 clients' files were reviewed and contained all required documentation. LPA observed first kit to be locked and inaccessible to the clients in care. The clients files were kept locked and inaccessible to unauthorized individuals.

Health-Related Services/Incidental Medical Services: All clients' medications were securely locked in a cabinet and located in the kitchen. LPA reviewed medications for 3 clients confirming that all medication were listed and accounted for.

Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, which met the department's requirements. LPA could not verify the latest emergency drill conducted at the facility. No documentation was present during the visit. A citation will be issued. . All facility exits were clear of obstructions.


Deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed, and a copy of this report, 809-C, 809-D and the appeal rights was provided to Caregiver Khalid Abdalla.
NAME OF LICENSING PROGRAM MANAGER: Rikesha Stamps
NAME OF LICENSING PROGRAM ANALYST: Abdoulaye Zerbo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/30/2025 12:10 PM - It Cannot Be Edited


Created By: Abdoulaye Zerbo On 06/30/2025 at 11:15 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: HOPE ARF
FACILITY NUMBER: 371881399

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
80066 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above with Staff and the Administrator's files which were not at the facility for licensing review which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2025
Plan of Correction
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The licensee is to send the LPA a copy of both staff and Administrator's file to review by POC due date. LPA has provided a copy of LIC311C
Type B
Section Cited
HSC
1569.695(c)
1569.695 Emergency Plans (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... Documentation of the drills shall include the date, the type of emergency covered by the drill, and 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 interview and record review, the licensee did not comply with the section cited above. LPA was unable to confirm if the facility is conducting the required Emergency Disaster Drills. No documentation was present at the facility during today's inspection, which poses a potential safety risk to persons in care.
POC Due Date: 07/29/2025
Plan of Correction
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Licensee will send proof the latest emergency drill conducted to LPA by POC due date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Rikesha Stamps
NAME OF LICENSING PROGRAM MANAGER:
Abdoulaye Zerbo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2025


LIC809 (FAS) - (06/04)
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