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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423875
Report Date: 02/07/2025
Date Signed: 05/07/2025 08:49:46 AM

Document Has Been Signed on 05/07/2025 08:49 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MISSION OF LOVE IIFACILITY NUMBER:
366423875
ADMINISTRATOR/
DIRECTOR:		JESSICA V. VILLANUEVAFACILITY TYPE:
740
ADDRESS:11991 7TH AVENUETELEPHONE:
(760) 947-5211
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 14CENSUS: 10DATE:
02/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Jessica Villanueva-LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Caregivers, Christian Avila and Anita Oja and introduced self and stated purpose of the visit. LPA was informed that there are currently 10 residents in care who are in the facility.

The facility has 7 resident bedrooms, 2 staff bedrooms, 3 bathrooms, kitchen, dining area, living room, laundry area, office area, 2 detached garages, and backyard. LPA completed a walk through of facility, and review of records.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 70 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 119.9 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, fire extinguisher and first aid kit. Posters such as; the personal rights, ombudsman, CCL complaint poster and license were posted in a common area. LPA also observed cleaning supplies, toxins, sharps, and other dangerous items locked in cabinets made inaccessible to residents. There was a designated storage space for resident/staff files. Medications were observed secured and inaccessible to residents. There are no bodies of water, guns or ammunition in the facility.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a wide variety of food available for residents. Dishes, cups, and utensils were also stored properly.
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Michelle Echeverria
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2025
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 4
Document Has Been Signed on 05/07/2025 08:49 AM - It Cannot Be Edited


Created By: Michelle Echeverria On 02/07/2025 at 12:06 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: MISSION OF LOVE II
FACILITY NUMBER: 366423875

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)(1)(D)
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. (1) The Infection Control Plan shall include all of the following: (D) The licensee shall review the use of infection control procedures in the facility at least annually, if local government public health determines an epidemic outbreak has occurred, or if the review is requested by the local licensing agency.

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 by not reviewing/updating the Infection Control annually which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2025
Plan of Correction
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Licensee stated that she will review/update the Infection Control annually and send a statement of understanding on the regulation cited by POC due date via email to LPA.
Type B
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

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 having an active and operating fire alarm/sprinklers services which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2025
Plan of Correction
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Licensee stated that she scheduled an appointment for fire alarm/sprinklers activation. Licensee will submit proof to LPA via email by 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2025


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/07/2025 08:49 AM - It Cannot Be Edited


Created By: Michelle Echeverria On 02/07/2025 at 12:06 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: MISSION OF LOVE II
FACILITY NUMBER: 366423875

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

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 by not reviewing/updating the Emergency Disaster Plan annually which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2025
Plan of Correction
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Licensee stated that she will review/update the Emergency Disaster Plan annually and send a statement of understanding on the regulation cited by POC due date via email to LPA.
Type B
Section Cited
CCR
87618(b)(3)(A)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility.

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 sending a letter to the local fire jurisdiction for oxygen administration in the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2025
Plan of Correction
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Licensee stated that she will send a letter to the local fire jurisdiction for oxygen administration and provide a copy to the LPA via email by 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2025


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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MISSION OF LOVE II
FACILITY NUMBER: 366423875
VISIT DATE: 02/07/2025
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Yards/Outside: One shaded patio, a side gate with self-latching handle on the left and right side of the house that leads into the backyard, and 2 detached garages used for storage. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPA reviewed 5 resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed personnel and administrator files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA reviewed the facility's insurance coverage, emergency disaster plan, infection control plan and emergency drills. LPA observed that the Infection Control Plan was not reviewed/updated annually. Deficiency issued. LPA observed that the Emergency Disaster Plan was not reviewed/updated annually. Deficiency issued. LPA observed oxygen administration in the facility. LPA observed through interview that the licensee did not have a report sent to the local fire department for oxygen used in the facility. Deficiency issued. LPA observed that the licensee disconnected the fire alarm/sprinklers servicing. Deficiency issued.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D and appeal rights were discussed and copies were provided to the Licensee, Jessica Villanueva who arrived during the facility tour.

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Michelle Echeverria
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025
LIC809 (FAS) - (06/04)
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