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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881430
Report Date: 10/13/2025
Date Signed: 10/13/2025 01:50:42 PM

Document Has Been Signed on 10/13/2025 01:50 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:CASA DEL SOL RESIDENTIALFACILITY NUMBER:
331881430
ADMINISTRATOR/
DIRECTOR:		KHAN, MUSARRATFACILITY TYPE:
740
ADDRESS:27830 BRODIAEA AVENUETELEPHONE:
(909) 282-2316
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 6CENSUS: 5DATE:
10/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Administrator, Musarrat KhanTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On 10/13/2025, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced 1-year required annual visit. LPA was greeted by care staff, Darlene Shepard, and was granted entry into the facility. LPA informed Darlene of the purpose of the visit. LPA conducted a tour of the facility and observed the following during the tour:

The facility is a single-story building which consists of (3) three residents bedrooms, (1) one staff bedroom, (2) two bathrooms, living room, dining room, garage, kitchen, and backyard. There is no pool and/or bodies of water. LPA observed the kitchen area to be clean and free of debris. Knives and other sharp items are located in a locked pantry in the kitchen. Centrally stored medication was also observed in the locked pantry inaccessible to residents. The facility maintained (2) two refrigerators which held the required (2) two day supply of perishable foods. LPA observed a (7) seven-day supply of non-perishable foods. Facility maintain emergency food and water supplies in the garage. LPA observed resident bedrooms to have the required bedding, furniture, seating, and functional lighting. Bathrooms were equipped with grab bars and skid resistant mats in the shower area. Indoor/Outdoor passageways were free from obstruction. Emergency disaster drills are conducted quarterly and range from scenarios. The facility operates their own laundry services; washer and dryer were observed to be in good repair and operable. Additional linen and towels are available for residents and appear to be in good repair. LPA observed the hot water temperature to meet requirements at 109.8°F. Per Administrator, Musarrat Khan, there are no firearms or ammunition on the premises.

(Continue to LIC809...)
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Valerie Flores
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2025
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 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: CASA DEL SOL RESIDENTIAL
FACILITY NUMBER: 331881430
VISIT DATE: 10/13/2025
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(Continuation from LIC809)

Facility sketch, residents personal rights, LTCO, and complaint poster are visibly posted on the walls throughout the facility. Facility staff records review include but are not limited to criminal record clearance, health screenings, TB result, First-aid/CPR training, and relevant training's to provide Assistance with Activities of Daily Living (ADL's). Resident records included but not limited to signed admission agreements, pre-admission assessments, physician reports, property and valuables, and needs/service plans. LPA reviewed (3) three out of (5) five residents Medication Administration Records. LPA conducted observations and records review conducted of the medication and medication administrator records, LPA observed multiple discrepancies. Therefore, deficiencies will be cited during today's visit.

An exit interview was conducted and a copy of this report along with LIC9099D, LIC811 and appeal rights will be provided to Administrator, Musarrat Khan.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Valerie Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/13/2025 01:50 PM - It Cannot Be Edited


Created By: Valerie Flores On 10/13/2025 at 01:04 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: CASA DEL SOL RESIDENTIAL
FACILITY NUMBER: 331881430

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(e)


This requirement is not met as evidenced by: (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.
Deficient Practice Statement
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Based on records review and observation, the licensee did not comply with the section cited above in (1) one out of (5) five residents did not have a prescription label on (4) four of their medications listed on the Medication Administration Record (MAR) although w Resident #1 had a prescription order for the medication listed on the MAR which poses an potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2025
Plan of Correction
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Administrator Masurrat agreed to request a prescription label for all medications from the pharmacy and/or refill the medication through the pharmacy to have a label placed on the medication. Administrator will take photo proof of the correction and email the photo to Licensing Program Analyst (LPA) Valerie Flores by Close of Business on 10/28/2025.
Type B
Section Cited
CCR
87465(c)(3)


This requirement is not met as evidenced by: c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.
Deficient Practice Statement
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Based on observations and records review, the licensee did not comply with the section cited above in (1) one out of (5) five residents as Resident #2 was not administered their medication as prescribed. Observations and records review, revealed medication signed off in Medication Administration Record (MAR) but medication was still in the packaging which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2025
Plan of Correction
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Administrator Masurrat agreed to have a Registered Nurse come in the facility and demonstrator proper medication handling and how to fill out a Medication Administrator Record. Administrator will provide Licensing Program Analyst (LPA) Valerie Flores a sign off sheet including what was covered, date of the training, and signatures of all participation staff. This form will be emailed to LPA by Close of Business on 10/28/2025.
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:
Valerie Flores
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2025


LIC809 (FAS) - (06/04)
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