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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426029
Report Date: 02/26/2025
Date Signed: 02/26/2025 04:30:02 PM

Document Has Been Signed on 02/26/2025 04:30 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:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Facility-Resident care director Melissa Bridges TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On 02/26/2025 at 9:00 AM, Licensing Program Analyst (LPA) Melody Brown and Licensing program Analyst (LPA) Beena Singh arrived at the facility, unannounced to conduct a Case Management visit.

LPAs Brown and Singh identified themselves and met with Resident care director Melissa Bridges and Licensee/Administrator Amelia Aladin was informed of the visit, who arrived during visit. LPAs informed Licensee/Administrator Aladin that this visit is being conducted to follow-up on the facility’s compliance with Health & Safety Code Section 1569.38.

Health & Safety Code 1569.38 requires the licensee to post a written notice and the accusation notice received must be posted in a conspicuous location in the facility and shall remain posted until the deficiencies that gave rise to the accusation notice are resolved. During the tour of the facility on 02/26/2025, LPAs Brown and Singh observed that the accusation and written notice that the facility received was not posted, as required by law, at the front office window near the main entrance of the facility and inside the facility near the Activity Area, Medication Room and Dining Room.

During today’s visit, LPAs observed and/or licensee Amelia Aladin and Resident care Director Melissa Bridges verbally confirmed that:

1.) The accusations: #6224046403 and #6224046403B, were not posted at the facility, as required by law since 02/12/2025.
2.) Written notice in at least 14-point type were not posted in a conspicuous location in the facility since 02/12/2025.

Licensee/ Administrator Aladin was informed that a deficiency will be issued today.

An exit interview was conducted where this report, LIC809, LIC809D and Appeal Rights were discussed, and copies were provided to Licensee/Administrator 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
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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Document Has Been Signed on 02/26/2025 04:30 PM - It Cannot Be Edited


Created By: Beena Singh On 02/26/2025 at 09:51 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: CALOAKS SENIOR LIVING
FACILITY NUMBER: 336426029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/05/2025
Section Cited
HSC
15689.38(f)

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Health and Safety Code (HSC) 1569.38 Posting of licensing reports; disclosure... (f) The notice required to be posted pursuant to subdivision (e) shall remain posted until the deficiencies that gave rise to the notice are resolved. This requirement was not met as evidenced by:

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Licensee immediately posted the written notice and the accusation notice received in a conspicuous location in front of the medicine room, near the activity area and in the front office counter area during the visit. Plan of Correction (POC) cleared.


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Based on observation, interview and record review, the Licensee did not comply with the section cited above by not ensuring that the written notice and the accusation notice received were posted in a conspicuous location in the facility and shall remain posted until the deficiencies that gave rise to the accusation notice are resolved which poses potential health, safety, and personal rights risks to resident 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.
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)
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