331881544-5-13-2025-18-AS-JARA-DGN2PG-20250513173418

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881544
Report Date: 05/13/2025
Date Signed: 05/13/2025 05:34:39 PM

Document Has Been Signed on 05/13/2025 05:34 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:	MORENO BEACH HOUSE OF CARE		FACILITY NUMBER:	331881544
ADMINISTRATOR/ DIRECTOR:	CHEN, JOHN		FACILITY TYPE:	740
ADDRESS:	27765 SOLITUDE AVENUE		TELEPHONE:	(949) 441-9833
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY: 6		CENSUS: 5	DATE:	05/13/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:19 PM
MET WITH:	Staff, Lawrence Santos		TIME VISIT/ INSPECTION COMPLETED:	05:40 PM

NARRATIVE

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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced case management visit. LPA met with Staff, Lawrence Santos, and spoke with Licensee Angelica Ubungen over the phone who were informed of the purpose of the visit. LPA conducted record reviews, interview and a walk through.

The case management visit was in response to an SOC341 Suspected Dependant Abuse Report for Resident #1 (R1) self reported by the facility. The report stated R1 had been inappropriately touched by Resident #2 (R2) at 12:15am. R1 reported to care staff the following morning around 9:30am on the incident.

LPA conducted a tour of the facility. No immediate health or safety issues were observed. LPA attempted but R2 was unavailable for interview. Interview with R1 which revealed incident where R2 inappropriately touched R1. R1 stated staff addressed the issue and reported it and check on her at night.

LPA reviewed the staff scheduled showing staff coverage and on call staff at night. LPA conducted interview with (1) over night staff which revealed at 11pm R2 was observed looking at R1, when they returned to their room. Interview with the licensee revealed a meeting was conducted with R2's responsible party and have placed an alarm on R2's door to alert staff if the resident leaves their room. Record review for R1 and R2 revealed their LIC602 Physician's report and care plan did not document R1 or R2 need supervision at night.

Based on LPAs interviews and records review there are no health or safety concerns related to the incident report and no deficiencies were cited for the incident. An exit interview was conducted where this report was reviewed and provided.

NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Janira Arreola
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025

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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