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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412261
Report Date: 06/04/2025
Date Signed: 06/04/2025 10:28:18 AM

Document Has Been Signed on 06/04/2025 10:28 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:MICHAEL ANDREW CENTERFACILITY NUMBER:
336412261
ADMINISTRATOR/
DIRECTOR:		ROMEO LABASTIDAFACILITY TYPE:
740
ADDRESS:10904 ARIZONA AVETELEPHONE:
(951) 343-9197
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY: 6CENSUS: 5DATE:
06/04/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Romeo LabastidaTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado is conducting this unannounced case management visit on this date to check on the health, safety, and welfare of clients in care. LPA learned that five (5) clients currently reside at this facility with one (1) client hospitalized since March 17, 2025. Two (2) staff is currently present. LPA was later met by facility administrator Romeo Labastida.

During this visit LPA toured the facility on the inside and outside. LPA assessed the food supply and found that it exceeds the minimum requirement of a 2-day supply perishable and a 7-day supply of non-perishable foods. LPA toured the perimeter of the facility and observes that there are no obstructed pathways or doorways. LPA toured the living room and dining room. LPA notes that the facility is clean and well maintained. LPA toured resident bedrooms. LPA observed that the beds have the appropriate linens, that the clients have adequate clothing, closet and personal items displayed in their rooms. Clients and staff were interviewed.

Based on the information obtained today LPA does not observe any immediate threat to the health, safety, and welfare of the clients residing at this facility. There are one (1) deficiency being issued per Title 22, Division 6 of the California Code of Regulations.

This report, LIC809D, LIC811, and Appeal Rights was reviewed with Romeo Labastida, and copy provided at the time of the exit interview.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Yolanda Delgado
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2025
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 06/04/2025 10:28 AM - It Cannot Be Edited


Created By: Yolanda Delgado On 06/04/2025 at 09:59 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: MICHAEL ANDREW CENTER
FACILITY NUMBER: 336412261

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/05/2025
Section Cited
CCR
87355(b)

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Criminal Record Clearance: (e) All individuals...shall prior to working, residing or volunteering in a licensed facility: (b) Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption.
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Licensee agrees to complete and associate by end of business 6/4/2025 in order to continue to have S4and S5 work or be at the facility. Licensee to provide LPA Delgado with proof of submitted request by 5pm on the due date indicated.
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 This requirement was not met as evidenced by:
Based on observation and interviews, the Licensee did not comply with the above regulation with at least two staff (S4, S5). LPA Delgado learned that S4 and S5 are not associated to this facility. This is an immediate safety risk to all residents 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.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Yolanda Delgado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2025


LIC809 (FAS) - (06/04)
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