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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881026
Report Date: 05/12/2022
Date Signed: 02/01/2023 10:41:03 AM

Document Has Been Signed on 02/01/2023 10:41 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:HESPERIA SENIOR CAREFACILITY NUMBER:
361881026
ADMINISTRATOR:WANG, JIN AFACILITY TYPE:
740
ADDRESS:17583 SULTANA STREETTELEPHONE:
(760) 669-0109
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 18CENSUS: 11DATE:
05/12/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Raeann Rios, CaregiverTIME COMPLETED:
02:25 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Rayshaun Nickolas and Bernadette Allen conducted a case management visit in response to deficiencies cited at the facility. LPAs met with caregiver Reanne Rios and explained the purpose of the visit. Rios called the administrator, per the LPAs request.

During the visit, LPAs toured the facility and requested to review the resident's records. Rios could not provide the residents' medical records as asked because records were locked, and Rios stated not have access to the office key.

Based on observations and interviews made during today’s inspection, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations (CCR). An exit interview was conducted and a copy of this report, LIC 809D, and Appeal Rights were provided.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
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 3
Document Has Been Signed on 02/01/2023 10:41 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/17/2022 08:20 AM


Created By: Rayshaun Nickolas On 05/12/2022 at 01:49 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: HESPERIA SENIOR CARE
FACILITY NUMBER: 361881026

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/16/2022
Section Cited
CCR
87755(c)

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87755 Inspection Authority of the Licensing Agency (c)
The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours...

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Licensee shall provide access to residents' records to all staff. Proof of correction shall be submitted to LPA on the POC due date of May 16, 2022 by the close of business.
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This requirement was not met as evidence

The facility's staff could not provide the residents' records as requested by LPA. The facility staff did not have the key to access the records.
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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:Karen Clemons
LICENSING EVALUATOR NAME:Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document is an Amendment of Original Document on 05/17/2022 08:20 AM


Created By: Rayshaun Nickolas On 05/12/2022 at 01:55 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: HESPERIA SENIOR CARE
FACILITY NUMBER: 361881026

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/16/2022
Section Cited
CCR
87755(e)(2)

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87755 Inspection Authority of the Licensing Agency (c)

The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours...
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Licensee shall provide access to residents' records to all staff. Proof of correction shall be submitted to LPA on the POC due date of May 16, 2022 by the close of business.
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This requirement was not met as evidence

The facility's staff could not provide the residents' records as requested by LPA. The facility staff did not have the key to access the records.
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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:Karen Clemons
LICENSING EVALUATOR NAME:Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022


LIC809 (FAS) - (06/04)
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