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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530303
Report Date: 09/11/2025
Date Signed: 09/11/2025 11:49:06 AM

Document Has Been Signed on 09/11/2025 11:49 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:TEENEE'S HOMEFACILITY NUMBER:
365530303
ADMINISTRATOR/
DIRECTOR:		PARCHEJO, JERRYFACILITY TYPE:
740
ADDRESS:801 S WISTERIA AVENUETELEPHONE:
(818) 484-0061
CITY:BLOOMINGTONSTATE: CAZIP CODE:
92316
CAPACITY: 4CENSUS: 3DATE:
09/11/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Administrator Jerry ParchejoTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 9/11/2025, Licensing Program Analysts (LPAs) Edith Conchas and Magda Malcore conducted an announced visit to complete the Pre-licensing inspection. LPA met with Administrator Jerry Parchejo. The fire clearance was approved on 5/21/2025 for four (4) clients.

The facility is an Residential Care Facility for the Elderly (RCFE) licensed for a capacity of four (4). Three (3) non-ambulatory clients and one (1) bedridden. The facility is vendorized by Inland Regional Center (IRC).

The facility has five (5) bedrooms, two (2) bathrooms, a staff area, kitchen, dining area, living room, laundry area, backyard with sitting furniture, and attached garage. LPAs toured the interior and exterior areas of the facility. The following were inspected:

Client Bedrooms: All bedrooms have the required bedding and furniture, such as, clean mattresses/linen, night stands, dressers, chairs, and lighting.

Client Bathrooms: The bathroom appliances were operating in safe and sanitary condition. The water temperature was measured around 105 degrees Fahrenheit.

Kitchen and Dining Areas: Utensils and dishware are in good repair and ready for client use. Kitchen appliances and counter top were free of debris and in good repair. There was a locked and secured drawer where sharps and chemicals are stored under the sink. There was also non-perishable food inside the pantry cabinet and perishable food inside the refrigerator/freezer. The staff schedule and a Meal menu was also on display.

Continue LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Edith Conchas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2025
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: TEENEE'S HOME
FACILITY NUMBER: 365530303
VISIT DATE: 09/11/2025
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Staff Area: There is a safely locked and secure filing cabinet where clients and staff files are stored along with medications.

Common Sitting Areas: There is adequate seating in the common areas. The facility has a supply of activities for the clients. The facility is maintained at a temperature of 73 degrees Fahrenheit.

Posters: LPA observed House rules, Long Term Ombudsman, the facility sketch, disaster plan, Personal Rights, Infection Control, and the Community Care Licensing Complaint poster along with Resident council was on display. A current Liability Insurance was observed effective 6/4/2025 and expires 6/4/2026.

Component III: Component III was completed during todays inspection.

A copy of this report was provided to administrator Parchejo at the conclusion of the visit

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Edith Conchas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
LIC809 (FAS) - (06/04)
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