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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881685
Report Date: 04/24/2025
Date Signed: 04/24/2025 01:27:10 PM

Document Has Been Signed on 04/24/2025 01:27 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:A LUMINESCENT LIFEFACILITY NUMBER:
331881685
ADMINISTRATOR/
DIRECTOR:		HOANG, ALYSSAFACILITY TYPE:
740
ADDRESS:81399 AVENIDA COYOTETELEPHONE:
(626) 257-6239
CITY:INDIOSTATE: CAZIP CODE:
92201
CAPACITY: 6CENSUS: 0DATE:
04/24/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Alyssa Hoang, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On 4-24-2025 Licensing Program Analyst (LPA) Seo Jeon made an announced visit to the facility for the purpose of conducting a pre-licensing inspection. LPA met with Alyssa Hoang, Administrator, who accompanied LPA for the inspection. The Applicant has submitted an application for (6) residents (6 non-ambulatory and no bedridden). On 3-24-2025, the Riverside County Fire Department approved a fire clearance for which the applicant has applied for.

The home is a single story structure consisting of (4) bedrooms, (2) bathrooms, kitchen, formal dining room,, garage, backyard with a covered patio, and fenced pool with locked gate. The facility is utilizing video surveillance on the common areas of the home. The bedrooms were observed to have bed, lighting, night-stand, chest of drawers and area for sitting. The bathrooms had nonskid surface, and grab bars. There is plenty of extra linen (sheets, blankets, towels) that were observed to be in good repair. The smoke and carbon monoxide detectors were tested and found to be operable.

The hot water temperature was tested and was found to be within regulatory limits measuring at 110 degrees Fahrenheit. The facility is equipped with flashlights, and night lights. The facility has an emergency disaster plan, and infection control plan on file. The facility has a sufficient supply of dishes, cooking and eating utensils, that were observed to be in good repair. The facility food supply was observed to be sufficient as there were 2-day supply of perishable and a 7-day supply of nonperishable food items. The facility has an emergency food and water supply. There is a fully stocked first aid kit with manual.

Continued on LIC809-C......
NAME OF LICENSING PROGRAM MANAGER: Rikesha Stamps
NAME OF LICENSING PROGRAM ANALYST: Seo Jeon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2025
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: A LUMINESCENT LIFE
FACILITY NUMBER: 331881685
VISIT DATE: 04/24/2025
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The passageways, and ramps/inclines are clear and free from obstruction. The home has 2 fully charged fire extinguishers. The facility does not have any known guns or ammunition stored on grounds. The sharps/knives are stored in a locked cabinet in the kitchen. The medications will be kept in individual boxes that will be stored in a locked cabinet in the kitchen.

Upon entry to the home on the wall, the required postings (facility sketch, resident council, theft and loss policy, personal rights, PUB475 CCL/dept complaint poster and Long term Care Ombudsman) were observed to be posted.

The facility was observed to have activities to encourage socialization as well as a covered patio with plenty of outdoor space for walking and physical activities.

LPA observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. LPA has determined that the facility met the operational requirements for licensure. The Pre-licensing inspection is complete. The facility has satisfied all requirements in accordance with Title 22 California Code of Regulations.

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

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC809 (FAS) - (06/04)
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