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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530260
Report Date: 07/10/2025
Date Signed: 07/10/2025 11:37:49 AM

Document Has Been Signed on 07/10/2025 11:37 AM - 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:MINONA GARDEN RESIDENTIAL SENIOR CAREFACILITY NUMBER:
365530260
ADMINISTRATOR/
DIRECTOR:		COLUNGA, ELIZABETHFACILITY TYPE:
740
ADDRESS:22854 MINONA DRTELEPHONE:
(909) 222-4795
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY: 6CENSUS: 0DATE:
07/10/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Elizabeth Colunga AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 7/10/2025 at 08:50 AM, Licensing Program Analyst (LPA) Eldin Serrano conducted an announced visit to the facility for purpose of Prelicensing evaluation. LPA met with Applicant/Administrator Elizabeth Colunga. An initial application to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 06/05/2024 for a total capacity of six (6) of which six (6) can be nonambulatory and two (2) hospice care waiver. Fire clearance was granted on 09/19/2024 for six (6) non-ambulatory residents. LPA Serrano observed the following:

Structure:
Facility was a one (1) story house with four (4) resident bedrooms and two (2) bathrooms, living room, dining area/kitchen and laundry. There was an attached two (2) car garage in the left side of the house.

Heating/Cooling System:
Central heating and air conditioning system installed with one (1) central panel located in the hallway to
control entire house.

Bedrooms:
Each resident bedrooms accommodate any nonambulatory residents. All resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, nightstands, a lamp and an operable smoke/carbon monoxide alarm.

Bathrooms:
The two (2) resident/staff bathrooms have a working toilet, wash basin, grab bars, non-slip mat and shower with an adequate supply of toilet paper and soap. LPA Serrano tested the water temperatures in the residents' bathrooms. ***CONTINUED ON LIC 809-C***
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Eldin Serrano
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2025
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: MINONA GARDEN RESIDENTIAL SENIOR CARE
FACILITY NUMBER: 365530260
VISIT DATE: 07/10/2025
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***CONTINUED FROM LIC 809***
LPA Serrano verified water temperature was measured at 107.7 degrees Fahrenheit.

Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments
were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPA Serrano observed the stove to be operational. Refrigerator/freezer were in working condition. There is sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was in the laundry room. Laundry detergents and cleaning supplies were observed in a locked cabinet. Garage door is locked away from residents.

Living Room:
There was a living/family room with adequate seating for all clients and a working TV.

Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the restroom of the residence.

Yards/Outside:
Patio furniture for outdoor seating observed. Self-latching handle gate on both side of the house that leads
into the backyard. All outdoor pathways were free of obstructions.

Emergency Phone Numbers, and Exit Plan:
Facility sketch was observed posted near the main entrance. There was Let-Us-No poster, Ombudsman Poster.

Dementia Care Plan:
LPA Serrano observed and reviewed the Dementia Care Plan during the visit.

General items:
Three (3) fire extinguisher was charged and located in the kitchen, hallway, laundry room. eight (8) smoke detectors and two (2) carbon monoxide detectors were tested and were observed to be in working order. Resident records and staff records will be stored in a locked cabinet in the family room. First Aid kit with required components, First Aid Book and locked area for medication storage was observed. ***CONTINUED ON LIC 809-C***
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Eldin Serrano
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC809 (FAS) - (06/04)
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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: MINONA GARDEN RESIDENTIAL SENIOR CARE
FACILITY NUMBER: 365530260
VISIT DATE: 07/10/2025
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***CONTINUED FROM LIC 809***
LPA observed a facility phone and was operational as evidenced by LPA dialing the number. The phone number designated for the facility is 909-222-4795.

There is enough Emergency water supply and the required 72-hour emergency food supply for residents and staffs available at the facility. Component III was completed on this day as well.

Additionally, LPA Serrano observed facility having Visitor Sign In/Sign Out Sheet and Client Sign In/Sign Out Sheet, upon entering facility.

The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22, Division 6, Chapters 1 and 6 to ensure the health and safety of clients in care. Facility appears to be ready for licensure.

An exit interview was conducted, and a copy of this report, LIC809 was discussed and provided to
Applicant/Administrator Elizabeth Colunga.
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Eldin Serrano
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC809 (FAS) - (06/04)
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