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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881321
Report Date: 11/22/2024
Date Signed: 11/22/2024 02:29:17 PM

Document Has Been Signed on 11/22/2024 02:29 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:CANYON VIEW HOMEFACILITY NUMBER:
361881321
ADMINISTRATOR/
DIRECTOR:		VERMANI, NITINFACILITY TYPE:
740
ADDRESS:9220 OLD RANCH RDTELEPHONE:
(909) 244-0286
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY: 6CENSUS: 6DATE:
11/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Elva Valdivia-CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced visit to this facility to initiate an investigation on complaint 56-AS-20241120151735. LPA met with Caregiver, Elva Valdivia.

During the visit, LPA conducted observations, interviews with staff, and did a walk-through of the facility. LPA found the following issue:
  • LPA was not able to have access to records since lead staff left out of the state due to an emergency and took key with self.

This poses a potential health and safety risk to residents in care. Refer to LIC 809D for deficiencies cited.

An exit interview was conducted where this report, LIC809D, and appeal rights were discussed with and provided to caregiver, Elva Valdivia.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
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 11/22/2024 02:29 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 11/22/2024 at 01:54 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: CANYON VIEW HOME
FACILITY NUMBER: 361881321

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/27/2024
Section Cited
CCR
87755(c)

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87755(c) Inspection Authority of the Licensing
(c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal....and 87508(b).This requirement is not met as evidenced by:
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Licensee stated that he will make duplicate keys to the filing cabinets for records to be available upon request. Licensee stated that he will submit a statement of understanding to LPA via email by POC due date.
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Based on observation, and interview, the licensee did not comply with the section cited above by not providing access to the licensing agency to inspect, audit, and copy which poses an immediate health, safety or personal rights risk to persons 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024


LIC809 (FAS) - (06/04)
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