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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880912
Report Date: 03/09/2026
Date Signed: 03/09/2026 01:07:51 PM

Document Has Been Signed on 03/09/2026 01:07 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:A & A CARE AND WELLNESSFACILITY NUMBER:
361880912
ADMINISTRATOR/
DIRECTOR:		AKOPYAN, HELENFACILITY TYPE:
740
ADDRESS:16055 SEQUOIA STREETTELEPHONE:
(818) 588-2894
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 6CENSUS: 3DATE:
03/09/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Carla AlvaradoTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Staff, Carla Alvarado, and was granted entry to the facility. The facility is a Residential Care Facility for the Elderly (RCFE) and a level 4i Inland Regional Center vendor. Licensed capacity is (6) current census (3). LPA conducted 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). There are no obstructions to indoor and outdoor passageways. Outdoor activity space is shaded and enclosed by a gate. The facility is maintained at a temperature of 74 degrees Fahrenheit (F). LPA inspected Resident bedrooms. Resident bedrooms were equipped with mattresses, nightstands, storage space, and lighting. LPA inspected Resident bathrooms. Bathroom equipment was operating appropriately and bathrooms were equipped with grab rails. The hot water in resident's bathroom measured 106 degrees (F). LPA observed Resident #1 (R1's) bathroom shower was not kept clean. Heavy soap residue was observed on shower walls and doors.

The facility is equipped with operating smoke/carbon monoxide alarms, fire extinguisher, hallway night light, covered fireplace, and laundry equipment. Posters such as personal rights, CCLD complaint poster, Ombudsman poster, activities, facility license/sketch, emergency telephone numbers were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated space for client/staff files.

Food Service: Kitchen and dining areas were maintained clean. Non-perishable and perishable food supply is sufficient for number of clients in care. Dishes, cups, and utensils were also stored properly. The facility maintains a menu for review.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Magda Malcore
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2026
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 8
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: A & A CARE AND WELLNESS
FACILITY NUMBER: 361880912
VISIT DATE: 03/09/2026
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Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Health Related Services: The facility maintains a first aid kit with manual. The facility centrally stores and maintains clients medication records/medications in a locked cabinet.

Record Review: An emergency/disaster plan and infection control plan was available for review. LPA reviewed (3) resident files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed (3) staff files for First Aid/CPR certifications, CPI certifications, criminal record clearance, trainings, and health screenings. LPA observed no documentation of staff#1 (S1's) and staff#2 (S2's) annual Dementia training on file. LPA observed no documentation of (S1's) annual medication management training on file. Facility staff was informed that the facility's licensing fees are due May 11, 2026.

During today's visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, reports (LIC809/LIC809-C/LIC809-D) were provided with appeal rights to Staff Alvarado.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Magda Malcore
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2026
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 03/09/2026 01:07 PM - It Cannot Be Edited


Created By: Magda Malcore On 03/09/2026 at 11:48 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: A & A CARE AND WELLNESS
FACILITY NUMBER: 361880912

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2026

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
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Based on LPA observed, the licensee did not comply with the section cited above by heavy soap residue was observed on walls and doors in resident#1 (R1's) shower; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2026
Plan of Correction
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The Licensee/Administrator shall provide photos of clean R1's shower to the Licensing Division by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Magda Malcore
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/09/2026 01:07 PM - It Cannot Be Edited


Created By: Magda Malcore On 03/09/2026 at 11:48 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: A & A CARE AND WELLNESS
FACILITY NUMBER: 361880912

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.626(a)(2)
Other Provisions
(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (2) Eight hours of in-service training per year on the subject of serving residents with dementia. This training shall be developed in consultation with individuals or organizations with specific expertise in dementia care or by an outside source with expertise in dementia care. In formulating and providing this training, reference may be made to written materials and literature on dementia and the care and treatment of persons with dementia. This training requirement may be satisfied in one day or over a period of time. This training requirement may be provided at the facility or offsite and may include a combination of observation and practical application.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs record review, the licensee did not comply with the section cited above by not maintaing documentation of staff#1 (S1), and staff#2 (S2) annual Dementia training on file for review;which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2026
Plan of Correction
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The Licensee/Administrator shall submit to the Licensing Division, documentation S1's and S2's in-service Dementia training by 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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Magda Malcore
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2026


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 03/09/2026 01:07 PM - It Cannot Be Edited


Created By: Magda Malcore On 03/09/2026 at 11:48 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: A & A CARE AND WELLNESS
FACILITY NUMBER: 361880912

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(b)
Other Provisions
(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by not maintaining documentation of staff#1 (S1's) annual medication management training on file for review;which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2026
Plan of Correction
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The Licensee/Administrator shall submit to the Licensing Division, documentation of inservice medication management training for S1 by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Magda Malcore
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2026


LIC809 (FAS) - (06/04)
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