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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530291
Report Date: 06/02/2025
Date Signed: 06/30/2025 03:24:54 PM

Document Has Been Signed on 06/30/2025 03:24 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:MOONSTONE CARE HOMEFACILITY NUMBER:
365530291
ADMINISTRATOR/
DIRECTOR:		LOPEZ, ARMINDAFACILITY TYPE:
740
ADDRESS:950 S WILLOW AVENUETELEPHONE:
(619) 398-5169
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 6CENSUS: 4DATE:
06/02/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:16 AM
MET WITH:Arminda Beltran Lopez, LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:15 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 at Green Willow Home Care, to conduct an announced Pre-Licensing visit for a change of ownership and change of facility name to Moonstone Care Home. LPA was greeted by Licensee Arminda B. Lopez. LPA introduced self and stated purpose of the visit. Moonstone application was submitted on 09/04/2024 for 6 RCFE, Non-Ambulatory clients. Fire Safety Inspection clearance was granted for 5 Non-Ambulatory clients and 1 Bedridden. LPA toured the facility inside and outside and observed the following:

Structure: Facility is a one story house with five client bedrooms, one staff bedroom, two bathrooms, living room, family room, dining area, kitchen, pantry, laundry area, backyard and an attached two car garage.

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

Bedrooms: All bedrooms have the required bedding and furniture, such as, clean mattresses/linen, night stands, dressers, chairs, and lighting. Per facility sketch it states that bedroom #6 and bed #2 is for bedridden residents, which is currently unoccupied.

Bathrooms: The client bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap. The bathroom water temperature was measured 119.5, which is in regulation.
(See LIC809C)
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2025
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 3
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 3
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: MOONSTONE CARE HOME
FACILITY NUMBER: 365530291
VISIT DATE: 06/02/2025
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
Common Sitting Areas: There is adequate seating in the common areas. The facility has a supply of activities for the residents. During LPA tour of the facility, LPA observed resident watching an exercise video with staff assisting and encouraging residents to participate.

Kitchen/Laundry Room/ Garage: There was a locked and secured location where medication, sharps, chemicals and residents/staff files are stored. There was non-perishable food in the pantry and perishable food in the refrigerator. The water temperature was measured at 113.8 degrees Fahrenheit. The laundry machines is in a common area in the kitchen next to an exit to the backyard. The garage has an emergency supply of food, water, and hygiene items. Chemicals, laundry soap and toiletries were safely locked.



Backyard: There is covered patio, furniture and chairs in the backyard for residents to sit. There are two side gate with self-latching handle on the left and right side of the house that leads into the backyard and no bodies of water. All passageways were free from obstruction.

Fire extinguisher, carbon monoxide, firearms: There is one charged fire extinguisher in the facility. LPA observed operating smoke detectors and carbon monoxide alarms. The home does not have any firearms and ammunition.

Postings/ Facility Records: LPA observed required postings including the CCL complaint poster, emergency disaster plan, and facility sketch. LPA reviewed three (3) out of three (3) residents files for Physicians report, Admission agreement, Appraisal needs and service plan, and MARS. After careful review of records LPA observed that the file were free of discrepancies. LPA reviewed three (3) out of three (3) staff files. LPA reviewed staff files for the following records: Health Screening Reports, TB clearance, Personal Records, and background clearance. LPA observed files to be free of discrepancies.

First aid and telephone: The facility was equipped with a complete first aid kit. The facility has a functioning land line and telephone for clients use.

Pre-Licensing is complete and Comp III are complete and ready for licensure.


An exit interview was conducted, and this report LIC809 and LIC809C was discussed and provided to Licensee Arminda B. Lopez.
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3