361881034-2-4-2026-56-AS-AMAZ-DQYT4F-20260204132353

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881034
Report Date: 02/04/2026
Date Signed: 02/04/2026 01:24:08 PM

Document Has Been Signed on 02/04/2026 01:24 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:	BROOKDALE LOMA LINDA		FACILITY NUMBER:	361881034
ADMINISTRATOR/ DIRECTOR:	LUJAN, MARITZA		FACILITY TYPE:	740
ADDRESS:	25585 VAN LEUVEN STREET		TELEPHONE:	(909) 796-5421
CITY:	LOMA LINDA	STATE: CA	ZIP CODE:	92354
CAPACITY: 220		CENSUS: 115	DATE:	02/04/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:35 AM
MET WITH:	Maritza Lujan, Executive Director		TIME VISIT/ INSPECTION COMPLETED:	01:30 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 Wednesday, February 4, 2026, Licensing Program Analysts (LPAs), Andrew Martinez and Sarina Ramirez, made an unannounced visit to the facility to conduct a required annual inspection. LPAs met Executive Director, Maritza Lujan, and discussed the purpose of the visit. The facility is a Residential Care Facility for Elderly (RCFE) with a license capacity of (220) and current census of (115). LPAs were accompanied by Maintenance Director, William Cruz, to conduct a tour and general inspection of the facility which included but was not limited to the following: Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming poosl or similar bodies of water. The facility has sufficient space for residents’ activities. Six (6) resident bedrooms and bathrooms were inspected. Hot water temperatures in the 6 residents' rooms measured at 110.0 °F, 106.0°F, 107.4°F, 105.0°F, 108.0°F, and 112.4°F degrees Fahrenheit (°F). The facility is equipped with operating smoke alarm/carbon monoxide detectors, recently inspected at time of last fire drill completed by FDS Fire Drill Service on December 9, 2025 (12/09/25). Facility has operating laundry equipment, and telephone service. The facility has Personal Rights, Facility Sketch, Community Care Licensing Complaint, and Ombudsman posters, emergency telephone numbers, daily menu, activities memo, and facility license posted visibly in a common area. LPAs observed a resident's laundry detergent was left accessible to residents in care in the facility's laundry room after use by housekeeper. Bottle was immediately stored away by housekeeping staff. A Technical Violation will be issued. Food Service: Kitchen and dining areas were maintained cleaned. Perishable and nonperishable food supplies were observed sufficient for number of residents in care. Facility refrigerators and freezers were maintained in operating condition. Sharps were observed kept locked and inaccessible to resident in care.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Andrew Martinez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/04/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026

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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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: BROOKDALE LOMA LINDA	FACILITY NUMBER: 361881034
	VISIT DATE: 02/04/2026

NARRATIVE

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Health Related services: LPAs reviewed six (6) resident medications. Resident’s medications are labeled and centrally stored in a locked room.

Record Review: Eight (8) resident files reviewed were observed to be complete. Eight (8) staff files reviewed were observed to be complete. The facility has a recently reviewed Emergency and Disaster Plan, signed January 6, 2026 (01/06/26), and Infection Control Plan, signed January 21, 2026 (01/26/26), on file. The facility's liability insurance was observed current in compliance with Health and Safety Code (HSC) regulations.

Based on LPAs observations and records reviewed, a technical violation, with no deficiencies, is being cited per Title 22, Division 6, of the California Code of Regulations (CCR).

An exit interview was conducted and a copy of this Facility Evaluation Report LIC 809, LIC 809-C, LIC 9102, and letter of Appeal Rights were discussed with and provided to Executive Director, Maritza Lujan, at the conclusion of the visit.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Andrew Martinez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/04/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026

LIC809 (FAS) - (06/04)

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