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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336400004
Report Date: 09/29/2025
Date Signed: 09/29/2025 01:00:11 PM

Document Has Been Signed on 09/29/2025 01:00 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:MAYFLOWER GUEST HOME IIFACILITY NUMBER:
336400004
ADMINISTRATOR/
DIRECTOR:		CRISTINA FAJARDOFACILITY TYPE:
740
ADDRESS:11287 NORWOOD AVE.TELEPHONE:
(951) 351-9074
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY: 15CENSUS: 13DATE:
09/29/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Facility Administrator Cristina Fajardo TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Beena Singh and LPA Paola Guerrero made an unannounced visit to the facility. LPAs conduct the joint visit with Paxton Jackson, Facilities Project Planner (CCE) County of Riverside, Department of Public Social Services. (DPSS). LPAs arrived at the facility to conduct a case management visit to inspect the facility regarding mold and termite issues. LPA met with facility Administrator Cristina Fajardo and explained the purpose of today's visit.

The facility is an eleven (11) bedroom, and four (4) bathroom home with a kitchen/dining area, living room/activity room. The facility is the Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of fifteen (15) ambulatory residents and the current census is Thirteen (13) residents. LPA Singh was accompanied by Administrator Fajardo to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). While conducting an inspection of the facility LPAs observed termites dropping on the bed in bedroom #4 with one resident is currently occupying the room, this poses a potential health and safety risk for clients in care. While continuing the inspection LPAs inspected first restroom located on the first-floor to have mold on the ceiling, through the walls and inside the bathroom cabinets, LPAs observed personal care products and other hygiene items were being stored and exposed to mold, deficiencies will be issued.

Based on the observations made during today’s visit, two deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC809D were discussed and provided to Administrator Cristina Fajardo.

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Beena Singh
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2025
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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Document Has Been Signed on 09/29/2025 01:00 PM - It Cannot Be Edited


Created By: Beena Singh On 09/29/2025 at 11:28 AM
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: MAYFLOWER GUEST HOME II
FACILITY NUMBER: 336400004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/29/2025
Section Cited
CCR
87303(a)(1)

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87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
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Licensee shall repair and or replace the shower walls and provide proof to Licensing that they were repaired.
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not keeping termites free with a resident sleeping in the same room, which poses a health and safety risk and also a common downstairs restroom for the residents has mold on the ceiling and on the walls and cabinets,which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
09/29/2025
Section Cited
HSC87468.1(a)(2)

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Personal Rights of Residents in All Facilities General....(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:....(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Licensee shall repair and deal with mold issues and move resident#1 to another room as soon as possible and lock bathroom and bedroom with a sign on the doors "Out of service" until repaired. Licensee will send pictures of locked doors and sign and repair once done.
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Based on interviews, and record review, the licensee did not ensure that facility resident are safe and protected from termites and mold in bedroom#4 and mold in downstairs bathroom, based on title 22 regulation, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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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.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Beena Singh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2025


LIC809 (FAS) - (06/04)
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