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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530030
Report Date: 11/21/2025
Date Signed: 11/21/2025 01:50:19 PM

Document Has Been Signed on 11/21/2025 01:50 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CITY HOME SENIOR LIVINGFACILITY NUMBER:
335530030
ADMINISTRATOR/
DIRECTOR:		SMITH, NGINAFACILITY TYPE:
740
ADDRESS:1672 GOLDEN WAYTELEPHONE:
(951) 524-0039
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY: 6CENSUS: 4DATE:
11/21/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Caregiver Rutrece Dizadore TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Edith Conchas made an unannounced case management visit to this facility. LPA met with caregiver Rutrece Dizadore.

During today's visit, LPA did a walk-through of the facility. LPA found the following issues:
  • LPA called licensee, left a voicemail but was unable to communicate with them during the visit.LPA attempted to view facility records, staff records and client records. LPA spoke with the caregiver and was informed they do not have access to the office for files. LPA requested to speak to licensee and caregiver stated they have contacted her and is not responding. Two (2) deficiencies were cited.

  • LPA took a tour of the facility and found personal belongings labeled from a another resident in two other residents rooms. One was a perineal care spray and the other item was personal wet wipes. A citation was cited.

  • LPA observed a new resident whom recently moved in on November 15th, 2025. Had a breathing treatment in the closet with out any medication for use of the machine upon emergency. A deficiency was cited.

An exit interview was conducted where this report was discussed, and a copy was provided to Caregiver Rutrece Dizadore.
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Edith Conchas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2025
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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Document Has Been Signed on 11/21/2025 01:50 PM - It Cannot Be Edited


Created By: Edith Conchas On 11/21/2025 at 12:16 PM
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: CITY HOME SENIOR LIVING
FACILITY NUMBER: 335530030

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/05/2025
Section Cited
CCR
87412(f)

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87412 Personnel Records (f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours... records shall be subject to the following requirements: This regulation was not met as evidenced by:
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House manager will request a key from the administrator/licensee for the office. Will maintain access for licensing. And will send an image of the copy of the new key to LPA by POC date.
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Based on observation, the licensee failed to ensure provide access to staff files to LPA upon request. No staff had key access to obtain and provide files for review.
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Type B
12/05/2025
Section Cited
CCR87506(d)

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87506 Resident Records(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours... Removal of records shall be subject to the following requirements: This regulation was not met as evidenced by:
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House manager will request a key from the administrator/licensee for the office. Will maintain access for licensing. And will send an image of the copy of the new key to LPA by POC date.
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 Based on observation, the licensee failed to ensure provide access to residents file to LPA upon request. No staff had key access to obtain and provide files for review.
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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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Edith Conchas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/21/2025 01:50 PM - It Cannot Be Edited


Created By: Edith Conchas On 11/21/2025 at 01:01 PM
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: CITY HOME SENIOR LIVING
FACILITY NUMBER: 335530030

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2025
Section Cited
CCR
87307(3)

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87307Personal Accommodations and Services(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident...This regulation was not met as evidenced by:
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Caregiver removed items immediately.
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Based on observation, the licensee failed to provide individual perosanl care items for each resident. LPA observed personal care items (Perinneal wash) labeled R# in R1 bedroom and perrineal wipes labeled R4 in R2 room.
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Type B
11/24/2025
Section Cited
CCR87465(a)(2)

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87465Incidental Medical and Dental Care(a) (2) The licensee shall provide assistance in meeting necessary medical and dental needs... the licensee shall do so directly or make arrangements for this service...This regulation was not met as evidenced by:
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Staff will contact hospice agency to request updated medication list including breathing treatment dosage to have in facilty for resident in care.
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Based on observation, LPA observed no medication prescribed nor access to medication for breathing treatment for equipment use upon emergency for R2.
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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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Edith Conchas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2025


LIC809 (FAS) - (06/04)
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