<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530146
Report Date: 11/17/2025
Date Signed: 11/17/2025 05:36:39 PM

Document Has Been Signed on 11/17/2025 05:36 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:CASSANDRA'S CARE HOMEFACILITY NUMBER:
365530146
ADMINISTRATOR/
DIRECTOR:		ELLISON, CASSANDRAFACILITY TYPE:
740
ADDRESS:10175 GOLDEN YARROW LANETELEPHONE:
(909) 664-7137
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY: 6CENSUS: 4DATE:
11/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:55 PM
MET WITH:Maribel Park, House Manager TIME VISIT/
INSPECTION COMPLETED:
05:40 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
Licensing Program Analyst (LPA) LaVette Farlow arrived unannounced to conduct the required annual visit to the facility. LPA met with Caregiver, Cintia Espinoza Lopez, and introduced self and stated purpose of the visit. Cintia notified the Administrator and House Manager of LPA's arrival. LPA was informed that there are currently 4 residents the home.

The facility has 4 resident bedrooms, 1 staff room/ office, 2 bathrooms, kitchen, dining area, living room, attached garage, backyard with 2 shaded/cover areas. LPA completed a walk through of facility, review of records and medication audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 73 degrees Fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 116.3 and 117.9 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, 3 fire extinguishers and emergency kit. Posters such as; the personal rights, ombudsman and emergency disaster plans were posted in a common area. LPA observed cleaning supplies, toxins, sharps, and other dangerous items locked in cabinets made inaccessible to residents. There was a designated storage space for resident/staff files. Medications were observed in a secured filing cabinet and inaccessible to residents. There are no firearms, ammunition, swimming pool or bodies of water. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a wide variety of food available for residents. Dishes, cups, and utensils were also stored properly.
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2025
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 6
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)
Page: 2 of 6
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: CASSANDRA'S CARE HOME
FACILITY NUMBER: 365530146
VISIT DATE: 11/17/2025
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
26
27
28
29
30
31
32
Yards/Outside: One shaded patio, a side gate with self-latching handle on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPA reviewed three (3) resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed that one (1) out of two (2) was missing a current physician report. A deficiency cited. LPA requested three staff for review for First Aid/CPR certifications, criminal record clearances, training's, and health screenings. LPA observed all staff files were complete and in order. LPA observed the facility file for Infection Control Plan, Emergency Disaster Plan, Liability Insurance, and Fire drills. LPA observed the Infection Control Plan was missing a signature stating it was signed, updated, and or reviewed for 2025. A technical violation issued. Also, the Liability Insurance was not updated and available for review. A deficiency cited.

LPA conducted a random audit of two (2) residents medication. LPA observed that one (1) out of two (2) residents was missing initial for medications that was dispensed on the 16th and 17th of November. A deficiency cited.

During todays visit three (3) deficiencies and one (1) technical violation were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D and LIC9102TV were discussed and copies were provided to Manager Maribel Parks.

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

DATE: 11/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 11/17/2025 05:36 PM - It Cannot Be Edited


Created By: Lavette Farlow On 11/17/2025 at 05:14 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: CASSANDRA'S CARE HOME
FACILITY NUMBER: 365530146

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 2 residents in care by not ensuring the MARS was maintained with an initial and date the medication was dispensed prescription and nonprescription medication which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/18/2025
Plan of Correction
1
2
3
4
Administrator agrees to conduct a training on medication logging and dispensing medication and submit a statement of understanding by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 11/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 11/17/2025 05:36 PM - It Cannot Be Edited


Created By: Lavette Farlow On 11/17/2025 at 05:14 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: CASSANDRA'S CARE HOME
FACILITY NUMBER: 365530146

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, and record review, the licensee did not comply with the section cited above by not ensuring the facility maintained a current liability insurance policy which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2025
Plan of Correction
1
2
3
4
Administrator contacted the insurance company during the visits and agreed to ensure to have a policy within the next 48 hours. Administrator will submit proof by POC due date.
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, and record review, the licensee did not comply with the section cited above in 1 out of 2 residents by not ensuring a annual physician report was maintained in the residents file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2025
Plan of Correction
1
2
3
4
Administrator agrees to review all residents files and agrees update and maintain a current physicain report for all residents in care 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.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6