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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366410686
Report Date: 04/01/2026
Date Signed: 04/01/2026 06:18:10 PM

Document Has Been Signed on 04/01/2026 06:18 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:ALTA LOMA BOARD AND CAREFACILITY NUMBER:
366410686
ADMINISTRATOR/
DIRECTOR:		G CAYANAN/F CAYANANFACILITY TYPE:
740
ADDRESS:6368 MOONSTONE AVETELEPHONE:
(909) 941-8459
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY: 6CENSUS: 5DATE:
04/01/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:04 PM
MET WITH:Gina Cayanan, Licensee TIME VISIT/
INSPECTION COMPLETED:
06:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) LaVette Farlow made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Caregiver, Lailani Pineda and was granted entry to the facility. Caregiver Lailani notified the administrator of my arrival. LPA was accompanied by Gina Cayanan to conduct a general overall inspection, which included, but was not limited to, the following:
The facility has 5 bedrooms, 2 1/2 bathrooms, 1 staff bedroom, kitchen, dining area, living room, laundry area, garage and backyard. LPA completed a walk through of facility, review of records and medication audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). LPA observed no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 73 Degrees Fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 108.5 and 106.2 Degrees Fahrenheit. The facility has operational smoke detector or carbon monoxide alarms. The facility has charged fire extinguisher. LPA observed the facility has a first aid kit, and first aid book, all component available and accounted for.
***LIC809 continued***
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2026
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: ALTA LOMA BOARD AND CARE
FACILITY NUMBER: 366410686
VISIT DATE: 04/01/2026
NARRATIVE
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LPA reviewed 3 out of 3 staff files and all 3 files were complete. LPA reviewed staff files for Criminal Background Clearance, Health Screening Report, TB test and test results, required training, and CPR/First Aid. LPA reviewed and audited 2 out of 2 residents files for Admission Agreement, Physicians Report, and Needs and Service Plan. LPA observed 1 out of 2 residents was missing a current Physician report. The last documented report was dated 4/6/2024. A Deficiency cited.

At approximately 4:30 PM, LPA conducted a Medication audit. During the course of the audit LPA observed medication that was discontinued still being stored with dispensed medication. Medication that has been dispensed missing initials. Medications not accurately logged on the medication MARs sheet. This was PRN and daily prescribed medications. A Deficiency cited. LPA conducted a review of the facility file: Liability Insurance, Emergency Disaster Plan, Infection Control Plan, Resident Roster (LIC9020) Personnel Roster (LIC500). The facility did not have the Infection Control Plan (LIC9282) or manual for review. A Technical Violation issued. LPA observed the facility did not have a current Liability Insurance policy. Licensee stated they were in the process of negotiating the price. A Deficiency cited. LPA observed that the facility is conducting quarterly emergency drills.

During this visit three (3) deficiencies and one (1) technical violations, were cited per title 22, chapter 6 of the California Code of regulation. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV, and appeal rights were discussed and copies were provided to Licensee Gina Cayanan.

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 04/01/2026 06:18 PM - It Cannot Be Edited


Created By: Lavette Farlow On 04/01/2026 at 05:16 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: ALTA LOMA BOARD AND CARE
FACILITY NUMBER: 366410686

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

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 by not maintaining an active insurance policy which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
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Licensing agrees to review the regulation cited, complete a statement of understanding and provide proof of Liability Insurance by POC due date to LPA.
Type A
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can 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) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

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 2 out of 2 residents in care by not ensuring medication that was discontinued was removed and destroyed and not continuously stored with dispensed medication. Medication that has been dispensed missing initials. Medications not accurately logged on the medication MARs sheet. This was PRN and daily prescribed medications. A Deficiency cited.[count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2026
Plan of Correction
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Licensee agrees to review the regulation cited, conducted a training on medication error and procedures, complete a monthly centrally stored medication log, and review all residents file and update residents records by POC due date and submit to LPA.
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: 04/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 04/01/2026 06:18 PM - It Cannot Be Edited


Created By: Lavette Farlow On 04/01/2026 at 05:16 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: ALTA LOMA BOARD AND CARE
FACILITY NUMBER: 366410686

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and record review, the licensee did not comply with the section cited above in 1 out of 2 resident in care. LPA observed that R1 last documented Physician Report was 4/6/2024 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2026
Plan of Correction
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Licensee agrees to review the regulation, complete a statement of understanding, and provide a current Physician Report 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: 04/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2026


LIC809 (FAS) - (06/04)
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