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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881636
Report Date: 05/08/2025
Date Signed: 05/08/2025 04:30:23 PM

Document Has Been Signed on 05/08/2025 04:30 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:SAN JACINTO ASSISTED LIVING, LLCFACILITY NUMBER:
331881636
ADMINISTRATOR/
DIRECTOR:		ALMAZAN, LIBRERTY A.FACILITY TYPE:
740
ADDRESS:397 E. MAIN STREETTELEPHONE:
(909) 845-8192
CITY:SAN JACINTOSTATE: CAZIP CODE:
92583
CAPACITY: 27CENSUS: 0DATE:
05/08/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Marilou Tumaliuan, ApplicantTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Seo Jeon conducted an announced visit to the facility for purpose of a Pre-Licensing inspection. LPA met with Applicant, Marilou Tumaliuan. An initial application to operate a Residential Care for the Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on 7-22-2024 for a total capacity of 27, (21) ambulatory and (6) bedridden residents. Fire clearance was granted on 11-18-2024. LPA Seo Jeon observed the following:

Structure:
Facility is consisted of 3 separate buildings for residents. 397 E. Main Street has 6 resident bedrooms, 1 shower room, and 3 half bathrooms (toilette and sink only). 377 E. Main Street has 3 resident bedrooms, 1 full bathroom, and 1 half bathroom (toilette and sink only). 350 S. Alessandro Ave has 7 resident bedrooms, 1 staff room, 2 full bathrooms, and 1 half bathroom (toilette and sink only). There is 1 fenced structure in the backyard for laundry equipment with locked gate.

Bedrooms:
All bedrooms in 397 E. Main and 377 E. Main are for ambulatory residents only. 350 S. Alessandro Ave is approved for 10 ambulatory and 6 bedridden residents. However, fire inspection report did not specify what rooms are approved for bedridden residents for 350 S. Alessandro Ave. LPA observed resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, and adequate lighting. Some of the bedrooms did not have required furniture and they are listed at the end of this report.

Continued on LIC809-C.....
NAME OF LICENSING PROGRAM MANAGER: Rikesha Stamps
NAME OF LICENSING PROGRAM ANALYST: Seo Jeon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2025
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 4
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: SAN JACINTO ASSISTED LIVING, LLC
FACILITY NUMBER: 331881636
VISIT DATE: 05/08/2025
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Bathrooms:
Bathrooms in all 3 buildings have a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 93 degrees Fahrenheit.

Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals for all residents. Washer and dryer were tested and operable. Laundry detergents and cleaning supplies were observed in secured laundry room inaccessible to residents. Sharps and knives need to be inaccessible to residents in care.

Living/Family room:


There is a living room in each building with adequate seating for all residents and TV.

Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the hallway of all 3 buildings.

Yards/Outside:
There is sufficient patio furniture for outdoor seating. There is no body of water in the premises. There are debris in the backyard that needs to be cleared out.

General items:
Total of 6 fully charged fire extinguishers are mounted on the walls of this facility. Client records will be stored in a locked cabinet. First Aid kit with required components, and locked cabinet for medication storage was observed. The facility food supply was observed to be sufficient as there was 2-day supply of perishable and a 7-day supply of nonperishable food items. The facility has an emergency food and water supply.

Continued on LIC809-C....

NAME OF LICENSING PROGRAM MANAGER: Rikesha Stamps
NAME OF LICENSING PROGRAM ANALYST: Seo Jeon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
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: SAN JACINTO ASSISTED LIVING, LLC
FACILITY NUMBER: 331881636
VISIT DATE: 05/08/2025
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Pre-Licensing is incomplete and the following corrections to be resolved. Applicant will advise LPA upon resolution of the following items.

obtain and post required postings
obtain locked storage for sharps and knives
adjust hot water temperature to be between 105 and 120 degrees F
install smoke alarms in all 3 buildings
remove debris in the backyard
remove locking door knobs and replace with passage door knobs
chest of drawers for each resident
remove third bed from 2 rooms in 350 S. Alessandro Ave


An exit interview was conducted, and a copy of this report was given.
NAME OF LICENSING PROGRAM MANAGER: Rikesha Stamps
NAME OF LICENSING PROGRAM ANALYST: Seo Jeon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC809 (FAS) - (06/04)
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