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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880887
Report Date: 04/08/2026
Date Signed: 04/08/2026 01:01:25 PM

Document Has Been Signed on 04/08/2026 01:01 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:ANCHETA'S PLACEFACILITY NUMBER:
361880887
ADMINISTRATOR/
DIRECTOR:		ANCHETA, EDNA AFACILITY TYPE:
740
ADDRESS:1350 OPAL AVENUETELEPHONE:
(909) 810-1044
CITY:MENTONESTATE: CAZIP CODE:
92359
CAPACITY: 2CENSUS: 2DATE:
04/08/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Licensee Edna AnchetaTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analysts (LPAs) E. Conchas and A. Martinez conducted an unannounced visit to the facility for an annual inspection. LPAs initially met with Licensee Edna Ancheta.

LPAs toured the facility inside and out. The facility has no bodies of water. The facility is equipped with two (2) fire extinguishers, neither of which have updated service tags; last service date is marked as October 5, 2023. A deficiency was cited. The facility had operating smoke detectors and a carbon monoxide alarm. Outdoor and indoor passageways were kept free of obstruction.

The outside of the facility had a shaded area with seating. Cleaning supplies, medications, and sharps were kept locked and inaccessible to the clients. Centrally stored medications were kept in a safe and locked place. LPAs toured the kitchen in which food was stored in a safe and healthy manner. The facility had sufficient food for residents in care. LPAs toured the residents’ bedrooms. The residents’ bedrooms had the required furniture and functional lighting.

The facility had a complete first aid kit. The facility did not have a current emergency disaster drill updated with resident information and did not have record of quarterly drills conducted; a deficiency was cited. The facility did not have an infection control plan available; a deficiency was cited.

LPAs toured the client bathrooms. The bathrooms were operating in safe and sanitary conditions. LPAs measured the hot water temperature in the bathroom. The hot water temperature measured 110.6 degrees F.

Continue to LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Edith Conchas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2026
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 04/08/2026 01:01 PM - It Cannot Be Edited


Created By: Edith Conchas On 04/08/2026 at 11:55 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: ANCHETA'S PLACE
FACILITY NUMBER: 361880887

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation], the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/09/2026
Plan of Correction
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LIcensee to provide proof of liability to LPA via email by POC date.
Type A
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
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Based on observation, the licensee did not comply with the section cited above by not having a current fire extinguisher. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/09/2026
Plan of Correction
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Licensee to service fire extinguisher by POC date and provide proof via email to LPA.
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: 04/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2026


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 04/08/2026 01:01 PM - It Cannot Be Edited


Created By: Edith Conchas On 04/08/2026 at 11:55 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: ANCHETA'S PLACE
FACILITY NUMBER: 361880887

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2026
Plan of Correction
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Licensee to update infection control plan and provide a copy to CCL by POC date via email
Type B
Section Cited
CCR
87411(d)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having any training completed in S1 file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2026
Plan of Correction
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Licensee to provide training to S1 and provide a copy to CCL by POC date via email.
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: 04/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/08/2026 01:01 PM - It Cannot Be Edited


Created By: Edith Conchas On 04/08/2026 at 11:55 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: ANCHETA'S PLACE
FACILITY NUMBER: 361880887

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not ensuring R1 had a current medication list of prescription which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2026
Plan of Correction
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Licensee to update R1 prescription medication and maitian in file. Provide a copy to CCL via email by POC date.
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having updated/completed forms in R1 file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2026
Plan of Correction
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Licensee to complete R1 file with required documentain and maintain it. Provide a copy of the completed documentation to to CCL by POC date via email.
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: 04/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
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: ANCHETA'S PLACE
FACILITY NUMBER: 361880887
VISIT DATE: 04/08/2026
NARRATIVE
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LPAs reviewed staff and resident files. Staff 1 (S1) did not have any training on file; a deficiency was cited. Resident 1 (R1) did not have completed documentation required in file. R1 did not have an appraisal, or needs and service plan completed. LPAs reviewed medications. LPAs observed medications for R1 without being properly documented on R1s centrally stored medication listing; a deficiency was cited. LPAs requested liability insurance for facility. Licensee informed LPAs they did not have any liability insurance for the facility; a deficiency was cited.

An exit interview was conducted where this Facility Evaluation Report was discussed and Plans of Correction were developed with Licensee. A copy of these reports (LIC 809, LIC 809-C), deficiencies (LIC 809-Ds), and appeal rights were discussed and provided to Licensee, Edna Ancheta.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Edith Conchas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 04/08/2026 01:01 PM - It Cannot Be Edited


Created By: Edith Conchas On 04/08/2026 at 12:33 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: ANCHETA'S PLACE
FACILITY NUMBER: 361880887

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)
(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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having a current emergency disaster plan or drill conducted which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2026
Plan of Correction
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Licensee to update the plans and conduct a drill for the month of April and provide a copy to CCL by POC date via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Edith Conchas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2026


LIC809 (FAS) - (06/04)
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