<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426029
Report Date: 02/26/2025
Date Signed: 02/26/2025 04:32:52 PM

Document Has Been Signed on 02/26/2025 04:32 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:CALOAKS SENIOR LIVINGFACILITY NUMBER:
336426029
ADMINISTRATOR/
DIRECTOR:		AMELIA ALADINFACILITY TYPE:
740
ADDRESS:3891 POLK STREETTELEPHONE:
(951) 689-6162
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY: 74CENSUS: 57DATE:
02/26/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Licensee/Administrator Amelia Aladin TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 02/26/2025 at 9:00 AM, Licensing Program Analysts (LPAs) Beena Singh and Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPAs Singh and Brown met with Resident Care Director Melissa Bridges and was granted entry to the facility. Licensee/Administrator Amelia Aladin was contacted and informed of the visit. At the time of the visit there were fifty-seven (57) residents present.

The facility is a forty (40) bedroom with a kitchen/dining area, living room/activity room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of seventy-four (74) non-ambulatory residents, hospice waiver for ten (10) residents and eight (8) bedridden residents. The current census is fifty-seven (57) residents. LPAs Singh and Brown were accompanied by Licensee/Administrator Amelia Aladin 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 (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPAs Singh and Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. However, LPAs observed no non-slip mats in resident's bathroom in room 29. Deficiency will be issued. LPAs observed sufficient furniture and lighting throughout the facility. LPAs measured hot water in residents room 36 had 136 degrees Fahrenheit water temperature and 130 degree f. in room 39. Deficiency will be issued. Water Temperature adjusted to 118 degrees F and 114 degrees F. during the visit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguishers were also observed at the facility.

***Continuation in LIC809C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CALOAKS SENIOR LIVING
FACILITY NUMBER: 336426029
VISIT DATE: 02/26/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Posters such as personal rights, Ombudsman Poster, labor laws, and the disaster plan were posted in a common area CCLD complaint poster posted in the common area.. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine Room with the resident’s medications locked. LPAs observed complete first aid kit and first aid book at the facility.

LPAs observed that blinds in room 20 and 37 were in disrepair. Deficiency will be issued. LPAs observed Window screens in room 4, room 34, room 40, room 38 with broken window screen. Deficiency will be issued.


Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. All kitchen staff have their updated ServSafe certification/food handler’s card. Also, LPAs observed facility having Emergency food and water, however, facility does not have the required emergency supplies maintained at the facility. Deficiency will be issued..

Care & Supervision: The facility has an appropriate number of staff present at the facility and enough hours to appropriately manage the facility. The facility has sufficient number of staff to provide care and supervision to the residents in care.

Record Review: LPAs Singh and Brown reviewed six resident files for admission agreements, updated physician reports, centrally stored medication list, pre-placement appraisals and needs and services plans. LPAs Singh and Brown observed resident files reviewed were complete. LPAs Singh and Brown reviewed six (6) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. LPAs observed staff files reviewed were complete. Medications were also audited for four (4) residents, however, During medication audit, LPAs observed that staffs at the facility are not assisting three (3) of four(4) residents with self-administration of medication. Deficiency will be issued. Also, During medication audit, LPAs observed that the facility is pre-pouring medications/transferring on the different container the AM medicine for next day as early as 9:30 AM. Deficiency will be issued.

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

An exit interview was conducted, and this report (LIC809),LiC 809C, LIC809D and Appeal Rights were discussed and provided to Licensee Amelia Aladin.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/26/2025 04:32 PM - It Cannot Be Edited


Created By: Beena Singh On 02/26/2025 at 03:03 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: CALOAKS SENIOR LIVING
FACILITY NUMBER: 336426029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above but not ensuring the hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2025
Plan of Correction
1
2
3
4
Licensee regulated the hot water used by residents at a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C during the visit today. Plan of correction (POC) cleared.
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation,interview,record review, the licensee did not ensure that staffs at the facility are assisting three (3) of four(4) residents with self-administration of medication, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2025
Plan of Correction
1
2
3
4
Licensee stated to train all staff on CCR 87465(a)(4) and submit proof of staff training log to LPA Singh by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Beena Singh
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 02/26/2025 04:32 PM - It Cannot Be Edited


Created By: Beena Singh On 02/26/2025 at 03:03 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: CALOAKS SENIOR LIVING
FACILITY NUMBER: 336426029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation,interview,record review, the licensee did not comply with the section cited above by not ensuring that facility staff are not pre-pouring medications/transferring on the different container the AM medicines for next day as early as 9:30 AM,which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2025
Plan of Correction
1
2
3
4
Licensee stated to train all staff on CCR 87465(h)(5) and submit proof of staff training log to LPA Singh by the Plan of Correction(POC) due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Beena Singh
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 02/26/2025 04:32 PM - It Cannot Be Edited


Created By: Beena Singh On 02/26/2025 at 03:03 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: CALOAKS SENIOR LIVING
FACILITY NUMBER: 336426029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(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.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by not ensuring that the blinds in room 20 and 37 were in good condition, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2025
Plan of Correction
1
2
3
4
Licensee stated to replace the broken blinds in room 20 and room 37 and submit proof to LPA Singh byt the Plan of correction(POC) due date.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by not ensuring that the window screens in room 4, room 34, room 40, room 38 are in good condition, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2025
Plan of Correction
1
2
3
4
Licensee stated to replace the broken window screen in roo-4,34,38,40 and submit proof to LPA Singh by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Beena Singh
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 02/26/2025 04:32 PM - It Cannot Be Edited


Created By: Beena Singh On 02/26/2025 at 03:03 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: CALOAKS SENIOR LIVING
FACILITY NUMBER: 336426029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by not ensuring that there is a non-slip mats in resident's bathroom in room 29. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2025
Plan of Correction
1
2
3
4
Licensee stated to obtain/purchase non-slip mat on room 29 and submit proof to LPA Singh by the Plan of correction(POC) due date. Licensee provided/placed non-slip mats in the room 29. POC cleared.
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview the licensee did not comply with the section cited above by not ensuring that facility has Emergency supplies and not just emergency food and water, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2025
Plan of Correction
1
2
3
4
Licensee stated to prepare/obtain/purchase the required emergency supplies and submit proof to LPA Singh by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Beena Singh
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2025


LIC809 (FAS) - (06/04)
Page: 6 of 6