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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530137
Report Date: 11/20/2025
Date Signed: 11/20/2025 02:01:01 PM

Document Has Been Signed on 11/20/2025 02:01 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:HILLS OF HAMILTON, THEFACILITY NUMBER:
365530137
ADMINISTRATOR/
DIRECTOR:		SHANELLREY KNOWLESFACILITY TYPE:
740
ADDRESS:10466 HAMILTON STREETTELEPHONE:
(714) 430-7672
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY: 6CENSUS: 0DATE:
11/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Joanna Gomez, Facility Director TIME VISIT/
INSPECTION COMPLETED:
02:05 PM
NARRATIVE
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On 11/20/2025 at 10:45 AM Licensing Program Analyst (LPA) LaVette Farlow arrived unannounced to conduct the required annual visit to the facility. LPA Farlow rang the doorbell and knocked on the door several times, no response. LPA Farlow called the facility phone number and spoke to Maricel Nepomuceno, and explained I was at the facility for the annual inspection. Maricel explained she was not available, and she would see if her Facility Director, Joanna Gomez was available. Maricel called me back and stated Joanna would meet me at the facility in approximately 10 minutes. At 11: 40 AM, Joanna arrived to the facility and LPA Farlow introduced self and stated purpose of the visit. LPA was informed that the facility current census is 0, and the last three residents moved out on Saturday, November 15, 2025 and Sunday, November 16, 2025. LPA Farlow requested the facility to provided the relocation information for the residents and the contact information for their responsible parties.

The facility has 4 bedrooms, 2 bathrooms, kitchen, dining area, family room, living room, washer and dry in the garage, attached garage, and backyard. LPA completed a walk through of facility, review of records, and reviewed the MARS.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. LPA observed the facility is currently empty and no residents were present in the facility neither were any personal belonging of the residents remaining in the facility. The facility temperature was 65 degrees Fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 113.0 and 108.1 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms and charged fire extinguisher, the last fire extinguisher inspection was conducted 6/19/2025. Posters such as; the personal rights, CCL complaint poster and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept secured and inaccessible to clients. There was a designated storage space for client/staff files. Since the facility is no longer housing any resident the wasn't any medication present.
*** Continued on LIC809C***
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2025
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 5
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: HILLS OF HAMILTON, THE
FACILITY NUMBER: 365530137
VISIT DATE: 11/20/2025
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LPA observed first aid/CPR kit was complete. All items were, secure and inaccessible to clients. The facility did have emergency kits in the facility for clients in care. There are no firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: LPA observed the facility had removed all perishable food items and still had available Non-perishable food supply. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed.

Record Review: LPA reviewed the facility files for three (3) residents files for admission agreements, updated physician reports, and needs and services plans. LPA observed that two (2) out of three (3) residents physician report had expired approximately 30 days ago. A technical violation issued. LPA also reviewed two (3) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. LPA observed the files were complete and maintained. LPA was unable to conduct a medications audited due to residents no longer residing in the facility. LPA did review the residents MARS and observed Caregiver did not initial the MARS for the three (3) out of three (3) residents prior to their last three (3) days living in the facility. A deficiency cited.

Based on the observations made during today’s visit, One deficiency and one (1) technical violation was cited, per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report LIC809, LIC809C, LIC809D, and appeal rights were discussed and provided to Facility Director, Joanna Gomez.

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 11/20/2025 02:01 PM - It Cannot Be Edited


Created By: Lavette Farlow On 11/20/2025 at 01:31 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: HILLS OF HAMILTON, THE
FACILITY NUMBER: 365530137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in three (3) out of three (3) residents in care by not ensuring the resident MARS was initialed, dated, and time stamp when medication was dispensed to the residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/05/2025
Plan of Correction
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Facility Director agrees to complete a statement of understanding of the regulation cited, and training with the procedure of dispensing, logging medication that has been dispensed, and common medication error.
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.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2025


LIC809 (FAS) - (06/04)
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