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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423954
Report Date: 03/04/2026
Date Signed: 03/04/2026 01:32:57 PM

Document Has Been Signed on 03/04/2026 01:32 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:WASHINGTON FAMILY MANORFACILITY NUMBER:
366423954
ADMINISTRATOR/
DIRECTOR:		WASHINGTON, SIMONEFACILITY TYPE:
740
ADDRESS:2235N. ARROWHEAD AVETELEPHONE:
(909) 562-4101
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY: 6CENSUS: 4DATE:
03/04/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Simone Ruth Harkless. House ManagerTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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On 3/4/2026 at 12:10 PM Licensing Program Analysts, LaVette Farlow and Paola Guerrero, (LPAs) arrived at Washington Family Manor unannounced to conduct the facility's Annual Inspection. LPAs Farlow and Guerrero were greeted and granted entry by Simone R. Harkless, House Manager. Simone R. notified the Administrator Simone Washington, of our arrival. LPAs was granted entry and provided space to work. LPAs later meet with and were greeted by Administrator Simone and stated purpose of the visit. LPAs were then accompanied by House Manager Simone R on a tour of the facility grounds.

Facility: LPAs was informed that the current census is 4. The facility is licensed 6 non-ambulatory residents. Dementia Care Plan in place. Hospice Waiver approval of 2 residents, and diabetic and glucose monitoring approved. LPAs observed that the facility is operating at the capacity and in the conditions approved by Community Care Licensing (CCL).



Physical Plant: LPAs observed the facility's temperatures to be comfortable. Sufficient lighting was provided by various lamps, fixtures and night-lights throughout the facility. LPAs observed carbon monoxide and fire alarms throughout facility. Administrator reports the facility conducts fire and disaster drills on a monthly basis. Fire extinguishers were observed to be fully charged January 22, 2026. The facility back yard contained a shaded space and adequate seating. The facility maintains its laundry room, extra hygiene and Personal Protective Equipment and extra supplies secure in the attached garage. The Living Room and Dining Room included activities, adequate seating and sufficient lighting. Please see LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2026
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: WASHINGTON FAMILY MANOR
FACILITY NUMBER: 366423954
VISIT DATE: 03/04/2026
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LPAs tested the water temperature and the water measure at 118.8, which is within regulation. Resident Rooms included all required furnishings such as beds with appropriate linens, night stand, adequate lighting and seating. The facility does maintain a room for live in staff and staff files, resident files and medications secure.

Food Service: LPAs observed the facility's food supply included a variety of items such as eggs, bread, milk, salad, fresh fruits and vegetables. Kitchen pantry with canned goods all in good standing. The amount of nonperishable and perishable food is sufficient for number of residents in care. LPAs observed that sharps, chemicals, cleaning supplies were kept in secure and inaccessible to residents in care.
Care & Supervision: Facility has sufficient care staff; who assist residents 24 hours and 7 days a week. Administrator reported that 2 staff member lives on facility grounds and other staff assist daily as part time caregiver. A review of staff files revealed that all staff files contained verification of their annual training, criminal record clearance, health screenings, TB test results and First Aid/CPR. The Administrator's Administrator Certificate was observed in compliance.
Resident Records: LPAs reviewed resident files for updated Physician's Report's, Needs and Services and Admissions Agreements. LPAs observed 3 out of 3 residents MARS and observed that the MARs were free of any discrepancy.
Signs / Poster Emergency Disaster Plan, Long Term Care Ombudsman, Administrator Certificate, Personal Rights and Facility Sketch, Facility License, SEE/SAY are posted in a prominent place.

Based on observations, staff interviews and record reviews, no deficiency cited per Title 22, California Code of Regulations. An exit interview was conducted and copy of this report reviewed and discussed, then provided to Administrator, Simone Washington.
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2026
LIC809 (FAS) - (06/04)
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