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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366410678
Report Date: 03/12/2025
Date Signed: 03/12/2025 04:29:25 PM

Document Has Been Signed on 03/12/2025 04:29 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:CANYON HILLS CARE HOMEFACILITY NUMBER:
366410678
ADMINISTRATOR/
DIRECTOR:		MELJORIE CASTELOFACILITY TYPE:
740
ADDRESS:7791 STEWART ROADTELEPHONE:
(909) 433-0612
CITY:COLTONSTATE: CAZIP CODE:
92324
CAPACITY: 6CENSUS: 5DATE:
03/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Myrna Sapigao, CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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On 3/12/2025 at 1:30 PM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Serrano met with Caregiver Myrna Sapigao and was granted entry to the facility. At the time of the visit there was two (2) staff present, and five (5) residents present. The administrator was out of town and the assistant administrator was not available at the time of the visit. The caregiver is the designated person.

The facility is a four (4) bedrooms, two (2) bathroom home with a kitchen/dining area, living room/activity room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) non-ambulatory, two (2) hospice care waiver and 1 maybe bedridden resident and the current census is five (5) residents. LPA Serrano was accompanied by Staff to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 70 degrees Fahrenheit. LPA Serrano inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA Serrano measured and observed the water temperatures in the bathroom to be at 105.2 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguishers were also observed at the facility. Posters such as personal rights, the CCLD complaint poster, labor laws, and the disaster plan were posted in a common area. LPA observed that the facility does not have the Infection Control Plan available for review. Deficiency will be issued

***Continuation in LIC809C ***

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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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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: CANYON HILLS CARE HOME
FACILITY NUMBER: 366410678
VISIT DATE: 03/12/2025
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Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine cabinet with the resident’s medications locked. LPA Serrano observed first aid kit and first aid book at the facility.

Food Service: Seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care.

Care & Supervision: The facility has sufficient number of staff to provide care and supervision to the residents in care. Also, LPA Serrano observed that the facility does not have dementia residents.

Record Review: LPA Serrano reviewed three (3) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. Medications/Medication Administration Record (MAR) were audited. LPA observed that resident #3 (R3) PRN was not properly recorded in the medication administration record (MAR). Deficiency will be issued. LPA Serrano reviewed two (2) staff and administrator files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed no issue.

Based on the observations and record reviews made during today’s visit, two (2) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report LIC809, LIC809C, LIC809D forms, and Appeal Rights were discussed and provided to Caregiver Myrna Sapigao.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/12/2025 04:29 PM - It Cannot Be Edited


Created By: Eldin Serrano On 03/12/2025 at 04:02 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: CANYON HILLS CARE HOME
FACILITY NUMBER: 366410678

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that the facility have an Infection Control Plan available for review. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2025
Plan of Correction
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Licensee will submit the Infection Control Plan by the plan of correction (POC) due date.
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that resident #3 (R3) PRN was properly recorded in the medication administration record (MAR) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2025
Plan of Correction
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Licensee will submit a statement of understanding of CCR 87465(d)(3) by the 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.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Eldin Serrano
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025


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