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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530229
Report Date: 11/10/2025
Date Signed: 11/10/2025 03:12:22 PM

Document Has Been Signed on 11/10/2025 03:12 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:MJ SENIOR HOMECARE SERVICES LLCFACILITY NUMBER:
365530229
ADMINISTRATOR/
DIRECTOR:		CHANIKORNPRADIT, MABELFACILITY TYPE:
740
ADDRESS:2172 N MAGNOLIA AVENUETELEPHONE:
(909) 258-2563
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY: 6CENSUS: 2DATE:
11/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:02 AM
MET WITH:Jenelle Wang, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) LaVette Farlow, arrived at MJ Senior Homecare Services LLC, to conduct an unannounced visit for the annual inspection. LPA was greeted by licensee, Jenelle Wang. LPA Farlow introduced self and stated the purpose of the visit. The facility licensed for a capacity of 6 residents (4) non-ambulatory residents and (2) bedridden residents. LPA Farlow toured the facility inside and outside and observed the following:

Structure: Facility is a one story house with (4) resident bedrooms, (2) resident bathrooms, office/staff area, living room, dining area, kitchen, pantry, backyard, and attached garage.

Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control entire house. The facility maintained a comfortable temperature of 72 degree Fahrenheit.

Bedrooms: One bedroom accommodates two non-ambulatory residents, two bedrooms accommodates one non-ambulatory resident in each room, and one bedroom accommodates two bedridden residents on the far right side of the house.

Bathrooms: The resident bathrooms have grab bars, working toilet, wash basin, and shower with an adequate supply of toilet paper and soap.

Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives, sharps, detergent, and chemicals are stored in locked cabinets/office. There was a pantry stocked with non-perishable food and perishable food found in the refrigerator. LPA observed the stove to be operational. Refrigerator/freezer were in working condition. Water tested in the bathroom faucet measured at 118.0 and 119.4 degrees Fahrenheit. A functional washer and dryer are located inside the garage.
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2025
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 7
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: MJ SENIOR HOMECARE SERVICES LLC
FACILITY NUMBER: 365530229
VISIT DATE: 11/10/2025
NARRATIVE
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Living/Family room: There was a furnished living room with reading books, puzzles and a TV observed.
Linens and Hygiene Supplies: An adequate supply of linens and hygiene supplies stored in a closet.
Yards/Outside: There is an enclosed Koi Pond, fruit trees, a shaded patio with seating area, two sheds on the left side of the house and a self-latching handle gate on the left side and right side of the house that leads into the backyard. All outdoor pathways were free of obstructions. There are no firearms, ammunition, swimming pool on the grounds.
Emergency Phone Numbers, and Exit Plan: Facility sketch, visiting rules, and personal rights were observed posted by the hallway/entrance.
General items: The smoke and carbon monoxide detectors were tested and are operable. There was two fully charged fire extinguishers observed. Resident/Staff records stored inside the locked office. First Aid kit with required components, and a locked area for medication storage was observed.
Facility files: LPA reviewed two (2) residents file for Admission Agreement, Needs and Service Plan, Physician Report, and MARS. LPA observed that two (2) out of two (2) resident was missing a Needs and Service Plan. A deficiency sited. LPA reviewed two out of two staff folder for Criminal Background Clearance, Health Screening, TB test result, Training, and CPR/First Aid Certificate. LPA observed that two (2) out of two (2) staff were missing one or more of the following items, Health screening, training, TB test results, and CPR/First Aid Certificate. A deficiency cited. LPA conducted a random audit of two (2) residents MARS and observed the MARS was missing signatures for several days and or one medication was not listed on the MARS. A deficiency sited. LPA observed the facility folder for the Personnel Report, Resident Roster, Liability Insurance, Emergency Disaster Plan, and Infection Control Plan. LPA observed the Personnel Report, Resident Roster, Emergency Disaster Plan and Infection Control Plan were not available for review and or had not been reviewed annually. A technical violation cited.

Based on the observations made during today’s visit, three (3) deficiencies and two (2) technical violation were cited per Title 22, Division 6, of the of the California Code of Regulations. A copy of this report LIC809, LIC809C, LIC809D, and appeal rights were discussed and provided to Administrator Jenelle Wang.
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 11/10/2025 03:12 PM - It Cannot Be Edited


Created By: Lavette Farlow On 11/10/2025 at 02:40 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: MJ SENIOR HOMECARE SERVICES LLC
FACILITY NUMBER: 365530229

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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, and record review, the licensee did not comply with the section cited above in two (2) out of two (2) resident in care by not ensuring the MARS and Centrally stored medication matched and ensuring that all medication had a date and signed initial after being dispensed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/11/2025
Plan of Correction
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Administrator agrees to complete a training for all staff regarding medication and dispensing of meds and submit a training log and statement of understanding by POC due date to LPA.
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: 11/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 11/10/2025 03:12 PM - It Cannot Be Edited


Created By: Lavette Farlow On 11/10/2025 at 02:40 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: MJ SENIOR HOMECARE SERVICES LLC
FACILITY NUMBER: 365530229

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain 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 two (2) out of two (2) by not ensuring all Personnel files are completed with required documents such as health screening, TB test results, CPR, training, etc which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/11/2025
Plan of Correction
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Administrator agrees to review and audit all staff personnel file for completeness and ensure that all records are updated by POC due date.
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in two (2) out of two (2) resident in care by no ensuring the all residents have a Needs and Service Plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/11/2025
Plan of Correction
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Administrator agrees to review and complete all required documents for each resident file by POC due and complete a statement of understanding to LPA.
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: 11/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2025


LIC809 (FAS) - (06/04)
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