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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880902
Report Date: 05/12/2026
Date Signed: 05/12/2026 03:42:36 PM

Document Has Been Signed on 05/12/2026 03:42 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:BUENA VISTA ASSISTED LIVINGFACILITY NUMBER:
331880902
ADMINISTRATOR/
DIRECTOR:		ICAMEN, ROBYNFACILITY TYPE:
740
ADDRESS:1393 S. BUENA VISTA ST.TELEPHONE:
(951) 658-5160
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 74CENSUS: 49DATE:
05/12/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Robyn Icamen, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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 On 5/12/2026, Licensing Program Analyst (LPA) Ahliah Sharp conducted an unannounced required annual visit. LPA met with Executive Director Robyn Icamen who was informed of the purpose of the visit. The facility’s current census is 49, with approval for fifty-eight (58) ambulatory, fifteen (15) non-ambulatory, one (1) bedridden resident; and a hospice waiver approved for eight (8) residents. LPA conducted a tour of the interior and exterior of the facility, reviewed facility documents and conducted five interviews; two (2) staff and three (3)residents. LPA observed the following:

LPA observed the physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good working conditions. The outdoor area was observed to be free of any hazards. LPA observed a courtyard with outdoor furniture and shaded area for residents. Facility kitchen had the ability to prepare food in a clean environment and possessed equipment in good working conditions. The sharp and dangerous objects were observed to be inaccessible to residents in the kitchen. Facility kitchen receives one shipment of food every week, ordered on Monday and arrives on Tuesday.

LPA observed the facility sketch, exit routes, personal rights, complaint information and emergency phone numbers posted around the facility. The smoke detectors and carbon monoxide detectors were operational. LPA observed the facility exceeded the required two (2) day supply of perishable and seven (7) day supply of non-perishable foods.

LPA conducted medication review with staff, and observed the medical sharps stored in locked boxes inaccessible to residents in care.

Continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Ahliah Sharp
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)
Page: 1 of 5
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: BUENA VISTA ASSISTED LIVING
FACILITY NUMBER: 331880902
VISIT DATE: 05/12/2026
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Continued from LIC809...

Staff files review included, but are not limited to, personnel records, criminal record clearance, required training, and valid first aid/CPR certification. The employee health screenings had been removed when the new company took over. They were advised that they would need to be made available in the employee files. Resident files included but are not limited to signed admission agreements, pre-placement, personal rights, needs and service plans, and updated physician reports.

LPA reviewed the facility's emergency and disaster plan. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies and first aid kit with all required items. Facility contained multiple charged fire extinguishers last serviced in March 2026, and Fire and Earthquake drills were last conducted on April 15, 2026. LPA observed all six (6) of the thermostat temperatures ranging from 75-78 degrees F.

LPA advised ED about the water temperature needing to be a little warmer even though the resident was comfortable with the current temperature of 99.9F and the access to the health screenings of the staff need to be placed back in the staff files. No deficiencies were cited at the time of the visit.

An exit interview was conducted where a copy of this report was provided to ED Robyn.

NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Ahliah Sharp
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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