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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881518
Report Date: 04/07/2025
Date Signed: 04/07/2025 11:44:08 AM

Document Has Been Signed on 04/07/2025 11:44 AM - 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:BOUNTIFUL GARDENSFACILITY NUMBER:
331881518
ADMINISTRATOR/
DIRECTOR:		WHITE, MALCOLM EFACILITY TYPE:
740
ADDRESS:291 BRANDON WAYTELEPHONE:
(619) 347-2140
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY: 6CENSUS: 3DATE:
04/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:13 AM
MET WITH:Caregiver, Sunny RoseteTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Debbie Palacios made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Caregiver Sunny Rosete who was informed of the purpose of the visit. The facility has a fire clearance for six (6) Non ambulatory residents and serves Ages range 60 and over. Staff present has a criminal record clearance and are associated with the facility.

LPA toured the facility and reviewed records. During the tour, LPA observed the facility is made up of a one-story home with six (6) resident bedrooms, one (1) staff bedroom, one (office room) and three (3) bathrooms, two (2) resident bathrooms and one (1) staff bathroom, a living room, dining room, kitchen, and attached garage. All resident bedrooms had the required furniture, lighting, and closet storage. LPA toured the facility's exterior and observed outdoor pathways were free of obstructions. LPA toured the kitchen and observed the facility has a two-day supply and perishable foods and more than a seven-day supply of non-perishable foods that were observed to be properly stored and readily available. Knives and sharp instruments were secured in a locked kitchen cabinet under the sink. LPA toured the garage and observed no additional refrigerators nor resident items . LPA reviewed resident and staff file records. Resident files reviewed had updated Physician's report, Care Plan and Resident Appraisal. Staff files reviewed had the Department's required training records and valid first aid/CPR certification. LPA was unable to review Fire and Earthquake quarterly drills; there was no proof of documents on file (Deficiency Cited). LPA reviewed the physical medications and Medication Administration Record and did not discover any discrepancies. LPA also observed the facility has a locked cabinet in the hallway filled with additional cleaning solutions, disinfectants, and laundry detergents.
NAME OF LICENSING PROGRAM MANAGER: Tricia Danielson
NAME OF LICENSING PROGRAM ANALYST: Debbie Palacios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2025
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: BOUNTIFUL GARDENS
FACILITY NUMBER: 331881518
VISIT DATE: 04/07/2025
NARRATIVE
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LPA also observed additional clean towels, blankets, and linens for the residents stored in the hallway closet. LPA observed three (3) fire extinguishers mounted throughout the facility without serviced tags or receipts as proof of service were not provided (Deficiency Cited).

Based on facility missing Fire and Earthquake drill documentation and expired extinguisher's, a deficiency will be cited.


An exit interview was conducted. A copy of this report, LIC 809-D, and the appeal rights were provided to caregiver Sunny Rosete.
NAME OF LICENSING PROGRAM MANAGER: Tricia Danielson
NAME OF LICENSING PROGRAM ANALYST: Debbie Palacios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/07/2025 11:44 AM - It Cannot Be Edited


Created By: Debbie Palacios On 04/07/2025 at 11:10 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: BOUNTIFUL GARDENS
FACILITY NUMBER: 331881518

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(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. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. 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 LPA's observation, interviews and record review, the licensee did not comply with the section cited above on not conducting quarterly Fire and Earthquake drills to staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2025
Plan of Correction
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Licensee agrees to conduct a fire drill with staff and will submit proof of fire and Earquake drills to LPA by the plan of correction date 05/07/2025. Licensee agrees to conduct quarterly fire drills for each staff.
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.
Tricia Danielson
NAME OF LICENSING PROGRAM MANAGER:
Debbie Palacios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/07/2025 11:44 AM - It Cannot Be Edited


Created By: Debbie Palacios On 04/07/2025 at 11:18 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: BOUNTIFUL GARDENS
FACILITY NUMBER: 331881518

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
Fire Safety: All facilities shall be maintained in comformity with the regulations adopted by the State Fire Marshall for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, interview, record review, the licensee did not comply with the section cited above, LPA observed that three (3) fire extingushers did not have a service tag or any receipt as proof of service which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2025
Plan of Correction
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Licensee will replace expired fire extingushers by POC due date.
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.
Tricia Danielson
NAME OF LICENSING PROGRAM MANAGER:
Debbie Palacios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2025


LIC809 (FAS) - (06/04)
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