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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424426
Report Date: 03/06/2026
Date Signed: 03/06/2026 12:32:10 PM

Document Has Been Signed on 03/06/2026 12:32 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:VINEYARD RESIDENTIAL II, THEFACILITY NUMBER:
366424426
ADMINISTRATOR/
DIRECTOR:		ARNOLD P. MANSATFACILITY TYPE:
740
ADDRESS:21292 CHARDONNAY DRIVETELEPHONE:
(760) 961-2658
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 6CENSUS: 3DATE:
03/06/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Mayleen SaludezTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met Administrator, Mayleen Saludez, and discussed the purpose for the visit. The facility is a Residential Care Facility for Elderly (RCFE) with a license capacity of (6), and a current census of (3). LPA conducted a general inspection of facility, which included, but was not limited to, the following:

Operation/Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor space for resident activities. Outdoor activity space is enclosed with a latching gate. The facility is maintained at a temperature of 70 degrees Fahrenheit. Resident bedrooms were furnished with beds, night stands, chairs, bed linen and lighting. Resident bathrooms were maintained clean and fixtures were operating properly. The hot water temperatures in the bathrooms measured at 114 degrees Fahrenheit. The facility is equipped with operating smoke/carbon monoxide alarms, fully charged fire extinguisher, laundry equipment, door signal, emergency supplies/water and telephone service. The facility has posted in a common area Community Care Licensing complaint poster, Ombudsman poster, facility license, facility sketch, food menu, "oxygen in use" signs, emergency plan and telephone numbers. Sharps and cleaning solutions were kept locked. The facility has a designated area for resident and staff files.

Food Service: Kitchen and dining areas were maintained cleaned. Non-perishable and perishable food supply was sufficient for number of residents in care. Facility staff also maintain food items for residents with physician ordered modified diets. Cups, plates, and utensils were sufficient for residents in care.

**continued on LIC809-C**

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Magda Malcore
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2026
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VINEYARD RESIDENTIAL II, THE
FACILITY NUMBER: 366424426
VISIT DATE: 03/06/2026
NARRATIVE
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Health Related Services: The facility maintains a first aid kit with manual and medications were centrally stored in a locked area. LPA audited medications for three (3) resident. LPA observed medication for resident#1 (R1) was not administered as prescribed by physician's directions. One of R1’s medications, administered three times per day, includes a physician’s directions to hold the dose if R1’s systolic blood pressure (SBP) is greater than 130. The Administrator was not able to provide the LPA with documentation that R1's SBP readings were taken prior to administration to verify that SBP was below 130 as required by the physician’s directions. Deficiency cited.

Record Review: Resident files were reviewed for admissions agreements, physician’s reports, appraisals, needs and services plans. Files were complete. Staff files were reviewed for First Aid/CPR certifications, criminal record clearances, training, and health screenings. Files were complete. The facility has available an infection control plan, emergency/disaster plan, client registry, and liability insurance for review.

During today's visit, a deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where this report was discussed and a copy provided with appeal rights to Administrator Saludez.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Magda Malcore
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/06/2026 12:32 PM - It Cannot Be Edited


Created By: Magda Malcore On 03/06/2026 at 12:02 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: VINEYARD RESIDENTIAL II, THE
FACILITY NUMBER: 366424426

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(2)
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: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above by no staff verification of R1's SBP readings being taken prior to administration of medication to ensure that R1’s SBP is below 130 as required by the physician’s directions. Which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2026
Plan of Correction
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The Licensee shall retrain Administator and staff on medication management and provided documentation of inservice training to the Licensing Division 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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Magda Malcore
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2026


LIC809 (FAS) - (06/04)
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