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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530269
Report Date: 01/22/2026
Date Signed: 01/22/2026 05:01:05 PM

Document Has Been Signed on 01/22/2026 05:01 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:AURORA COMFORT CARE HOME INCFACILITY NUMBER:
365530269
ADMINISTRATOR/
DIRECTOR:		AMIRJANYAN, GEORGIFACILITY TYPE:
740
ADDRESS:5659 CAROL AVETELEPHONE:
(909) 833-8333
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY: 6CENSUS: 6DATE:
01/22/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Floretta Castro, House Manager, and Joseph Walker, House ManagerTIME VISIT/
INSPECTION COMPLETED:
05:10 PM
NARRATIVE
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Licensing Program Analysts (LPAs) LaVette Farlow and Andrew Martinez arrived at Aurora Comfort Care Home Inc to conduct an unannounced annual inspection. LPAs were greeted by Ryan Quiboloy, Caregiver. LPAs introduced themselves and stated purpose of the visit. LPAs met with House Managers Floretta Castro and Joseph Walker, and Floretta Castro escorted LPAs on a tour of the facility. During the tour the following was observed inside and outside:

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. The facility is equipped with a central heating and air conditioning system installed with the central panel located in the hallway to control entire house. Two bedrooms accommodate two non-ambulatory residents in each room, and two bedrooms across the hallway accommodating one non-ambulatory resident and 1 bedridden resident privately in each room. The resident bathrooms have working toilets, wash basins, and showers with an adequate supply of toilet paper and soap.

Kitchen/Bathroom/Laundry: An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives, sharps, detergent, and chemicals are stored in locked cabinets. The facility pantry has non-perishable and perishable food for residents in care. LPAs observed an insufficient amount of non-perishable food for the number of residents in care for 7 days. A Deficiency cited. LPAs observed the emergency food supply. Refrigerators and freezers are in working condition. Water tested in the bathrooms and kitchen faucet measured at 137.9, 135.9 and 126.1 degrees Fahrenheit. A deficiency cited. The facility has a washer and dryer located inside the garage.
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2026
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: AURORA COMFORT CARE HOME INC
FACILITY NUMBER: 365530269
VISIT DATE: 01/22/2026
NARRATIVE
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Living/Family Room/Hygiene Supplies: The facility has sufficient amount of furniture for number residents in care in living room with reading material and a TV observed. The facility maintained an adequate supply of linens and hygiene supplies stored in a closet for residents in care.

Yards/Outside: A self-latching handle gate on the left and right side of the house that leads into the backyard. There are no firearms, ammunition, swimming pool or bodies of water observed. LPAs observed the Licensee is completing construction on a second home in the backyard. The construction work is scheduled to be completed in the next 30 days. LPAs observed the left side of the house walkway has rocks that can be a potential hazard. LPAs recommended the area be cleared of any debris and hazards. A Technical Advisory issued.

Facility Files: The facility has an active landline telephone that LPAs verified. The facility maintained a facility sketch, visiting hours, See Something Say Something, and personal rights postings observed in the common areas. LPAs reviewed the facility files and observed the Licensee has not reviewed nor updated the Infection Control Plan and the Emergency Disaster Plan. A Technical Violation issued.

Record Review: LPAs reviewed three (3) residents file for Admission Agreement, Physician Report, and Needs and Service Plan. LPAs observed that 3 out of 3 residents file were maintained and complete. Medications/Medication Administration Records (MARs) were audited for three (3) residents. LPAs observed medication errors of the 3 residents (R1, R2, R3) with their medication(s) still in bubble pack(s) and not dispensed, as well as medication dispensed without being properly logged on the residents' MARs. Deficiency issued. LPAs reviewed three (3) staff files for Criminal Record Clearance, Health Screening, TB test results, CPR/First Aid, and Training. LPAs observed personnel file were maintained and complete.

General Items: The smoke and carbon monoxide detectors were tested and are fully operable. There is one fully charged fire extinguisher observed. First Aid kit with required components, and a locked area for medication storage was observed.

During today's visit, three (3) deficiencies were cited and three (3) technical violation or advisories are being issued in accordance with the California Code of Regulations (CCR), Title 22. A exit interview was conducted and a copy of this report LIC809, LIC809C, LIC809D, LIC9102 and letter of Appeal Rights were discussed and provided to House Managers Floretta Castro and Joseph Walker.
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 01/22/2026 05:01 PM - It Cannot Be Edited


Created By: Lavette Farlow On 01/22/2026 at 04:26 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: AURORA COMFORT CARE HOME INC
FACILITY NUMBER: 365530269

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not ensuring the water temperature was maintained and within regulations of 105-120 degrees Fahrenheit in the bathrooms and kitchen which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2026
Plan of Correction
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The Licensee agrees to review the regulation cited, and complete a statement of understanding. The Licensee will monitor the water levels for 7 days measuring it three 3x's a days and submit a log to LPA by POC due date.
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not ensuring the facility maintained a sufficient amount of non-perishable food supply for 7 days for the number of residents in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/24/2026
Plan of Correction
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Licensee agrees to review the regulation cited and purchase the food supply 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: 01/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2026


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 01/22/2026 05:01 PM - It Cannot Be Edited


Created By: Lavette Farlow On 01/22/2026 at 04:26 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: AURORA COMFORT CARE HOME INC
FACILITY NUMBER: 365530269

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2026

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 3 out of 3 residents by not ensuring the medication records agreed/complied with the medication dispensed/bubble packs. The medication MARs were missing initials and indicated future doses had been issued which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2026
Plan of Correction
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Licensee agrees to review the regulation cited and complete a training with all staff and submit a statement of understanding of the regulation. Licensee agrees to develop a concise plan to maintain the centrally stored medication log and the MARs log. Licensee with submit proof to LPA by POC due date.
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: 01/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2026


LIC809 (FAS) - (06/04)
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