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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881739
Report Date: 10/29/2025
Date Signed: 10/29/2025 10:57:12 AM

Document Has Been Signed on 10/29/2025 10:57 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:TRANQUALITY VALLEY ASSISTED LIVINGFACILITY NUMBER:
331881739
ADMINISTRATOR/
DIRECTOR:		FUENTES, TERESAFACILITY TYPE:
740
ADDRESS:26450 HELENE DRIVETELEPHONE:
(909) 548-1769
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 6CENSUS: 5DATE:
10/29/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:38 AM
MET WITH:Applicant, Nick VermaniTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Janira Arreola conducted an announced visit to the facility in order to conduct the prelicensing inspection. The LPA met with Applicant, Nick Vermani and with administrator Teresa Fuentes who was informed of the purpose of the visit. At the time of the visit there were (4) staff and (1) clients present.

The facility is seeking a change in ownership for a residential care facility for the elderly. The facility is a one story home with (4) bedrooms and (2) and a half restrooms. There are no pools or firearms located on the property. LPA conducted a tour of the facility and reviewed documents.

LPA observed the client bedrooms, bathrooms and common areas. Required furniture was present and in good repair. LPA observed where the client and staff records will be storage. The facility had the required postings. LPA observed where the cleaning supplies, and dangerous/ sharp objects are being kept locked and inaccessible to clients. LPA observed the smoke and carbon monoxide detectors in the facility were operational during the visit. The hot water was read at 113F. The facility has a working land line at (951) 807-3397. LPA observed first aide kit with all required items. The exits are free of obstructions, the facility has a documented fire drill and emergency supplies such as emergency lighting and food.
NAME OF LICENSING PROGRAM MANAGER: Carolyn Tuba
NAME OF LICENSING PROGRAM ANALYST: Janira Arreola
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2025
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: TRANQUALITY VALLEY ASSISTED LIVING
FACILITY NUMBER: 331881739
VISIT DATE: 10/29/2025
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LPA observed the client medications are being stored locked and in their originally received containers. LPA reviewed staff files which had required paperwork. The facility has operating video surveillance, LPA observed the cameras are in common areas and reviewed the consent forms will be part of the new admission agreement provided to facility residents. All staff present are finger print cleared and the licensee was advised on having all staff fingerprinted prior to working or residing at the facility.

An exit interview was conducted with the applicant.
NAME OF LICENSING PROGRAM MANAGER: Carolyn Tuba
NAME OF LICENSING PROGRAM ANALYST: Janira Arreola
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
LIC809 (FAS) - (06/04)
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