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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604307
Report Date: 07/09/2025
Date Signed: 07/09/2025 12:12:31 PM

Document Has Been Signed on 07/09/2025 12:12 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:WALK OF LIFE, ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
374604307
ADMINISTRATOR/
DIRECTOR:		LEWIS-BARRETO, ANNABELLEFACILITY TYPE:
735
ADDRESS:168 EVVIA COURTTELEPHONE:
(760) 295-5454
CITY:VISTASTATE: CAZIP CODE:
92083
CAPACITY: 6CENSUS: 6DATE:
07/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:William Lewis, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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On 07/09/25 Licensing Program Analyst (LPA Javina George conducted an unannounced annual required visit. LPA was granted entry by Caregiver Maria Rivera, where LPA informed of the purpose of the visit. Both the facility manager Maria Shriver and Administrator William Lewis arrived during the visit. At the time of the visit there was two (3) staff and one (1) client present, during LPAs visit. Four (4) clients were at the day program, and (1) is out at a Skilled Nursing Facility. The facility is licensed to serve age 18 through 59, approved for five (5) non ambulatory and (1) bedridden resident. In addition, the facility has an approved hospice waiver for (2). There are currently zero (0) clients receiving hospice services or bedridden.

The facility was observed to be clean and furniture was in good repair. The sharp and dangerous objects, chemicals and other hazardous items were observed to be locked and inaccessible to clients in care. The medications are locked in a medication cart, and the facility is using an electronic MAR software program. During the inspection of the facility interior LPA initially observed (2) of the combined smoke detector and carbon monoxide to not be operable as the batteries were pulled out in (2) different client bedrooms. A battery was pushed in and continuous beeping began. The administrator changed the battery before the conclusion of LPAs visit. However, the citation and civil penalties are still being issued due to it being evident/known that the batteries needed to be replaced, and there is zero tolerance for inoperable detectors. The emergency disaster drills are being conducted on a quarterly basis with the last drill being conducted on 06/10/25. The hot water temperature measured to be 105 degrees Fahrenheit. The facility food supply was sufficient as there was a 2-day supply of perishable and 7-day supply of non-perishable food items. Staff present were observed to have obtained criminal record clearance and to be associated to the facility. The CPR/First Aid Certification was observed to be valid with an expiration date of today 07/09/25. Staff were enrolled in CPR training during LPAs visit, and certificates will be provided to the department upon

NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Javina George
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2025
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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Document Has Been Signed on 07/09/2025 12:12 PM - It Cannot Be Edited


Created By: Javina George On 07/09/2025 at 10:30 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: WALK OF LIFE, ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 374604307

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 times as two client bedroom were observed to have the battery pulled out just enough to prevent the beeping which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2025
Plan of Correction
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The batteries were replaced by the conclusion of LPAs visit. The detectors were tested and found to be operable, therefore no POC is due at this time.
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.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Javina George
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2025


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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WALK OF LIFE, ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 374604307
VISIT DATE: 07/09/2025
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completion. The administrator was observed to possess a valid administrator certification, which expires on 10/28/26. A review of client files was conducted and were observed to have the required paperwork completed admissions agreement, Individual Program Plan (IPP), and medical assessment. In addition, a review of Personal and Incidental funds was conducted with no discrepancies found.

An exit interview was conducted where a copy of this report, 809C, 809D, appeal rights and LIC-811 Confidential names list was reviewed and provided to administrator William Lewis.

NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Javina George
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
LIC809 (FAS) - (06/04)
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