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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530331
Report Date: 10/31/2025
Date Signed: 10/31/2025 12:59:28 PM

Document Has Been Signed on 10/31/2025 12:59 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:WISTERIA SENIOR HOMEFACILITY NUMBER:
365530331
ADMINISTRATOR/
DIRECTOR:		MAHINAN, GUILLERMAFACILITY TYPE:
740
ADDRESS:28516 WISTERIA LANETELEPHONE:
(626) 705-0906
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY: 4CENSUS: 0DATE:
10/31/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Administrator, Guillerma MahinanTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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On 10/31/2025 at 10:50AM Licensing Program Analyst (LPA) Renese Howell-Small conducted an announced visit to the facility for the purpose of a Pre-Licensing evaluation. LPA met with Administrator, Guillerma Mahinan. An initial application to operate a Residential Care Facility Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on 7/11/2025 for a total capacity of four(4) non-ambulatory residents, with a Hospice waiver for four (4). Fire clearance was granted on 06/10/2025. LPA observed the following:

Structure:
Facility is a house with three (3) resident bedrooms, two (2) resident bathrooms, living room, dining area and kitchen. There was an attached two car garage in the front of the house.

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

Bedrooms:
All bedrooms are adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, Night light(s) will need to be added in the main hallway leading to shared bathroom. .

Bathrooms:
Both bathrooms have working toilets, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. The water temperature was measured at 122 degrees Fahrenheit. Administrator will adjust the water heater.

Kitchen:
The kitchen has an adequate supply of dishes, glasses, utensils and pots and pans. Knives/sharp instruments will be secured in a locked cabinet in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition.


NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Renese Howell-Small
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2025
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: WISTERIA SENIOR HOME
FACILITY NUMBER: 365530331
VISIT DATE: 10/31/2025
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Kitchen:
There was sufficient storage for perishable food. There was adequate seating for meals for all residents.

Laundry:
Laundry room with washer and dryer was located in the garage. Laundry detergents and cleaning supplies will be kept in the garage secured in a locked closet.

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

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

Yards/Outdoors:
There is sufficient covered seating in the backyard. The gate on the left side is the exit and is self-latching. All outdoor pathways were free of obstructions.

Emergency Phone Numbers and Exit Plan:
Facility sketches were observed posted in the main area close to the kitchen . There was one (1) fire extinguisher(s) and combination carbon monoxide/smoke detectors in resident rooms and in the hallways, which are working and in good condition.

General items:
Resident records will be stored in a locked cabinet in the dining area. First Aid kit with required components are located in the medication cart. Medication will be locked in the medication cart. LPA observed a facility phone and it was verified to be operational. Emergency water supply and food was observed.

An exit interview was conducted, no deficiencies were cited, Component III was completed during this visit and a copy of this report was reviewed and provided to Guillerma Mahinan. .

According to Title 22 California Code of Regulations, Licensee/Administrator Guillerma Mahinan has satisfied all of these requirements and is ready for licensure.
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Renese Howell-Small
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
LIC809 (FAS) - (06/04)
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