<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881428
Report Date: 09/12/2025
Date Signed: 09/12/2025 01:15:37 PM

Document Has Been Signed on 09/12/2025 01:15 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MOTHER DOLOROSA HOME CAREFACILITY NUMBER:
371881428
ADMINISTRATOR/
DIRECTOR:		RAMIREZ, JOSE RICARDO L.FACILITY TYPE:
740
ADDRESS:29533 MACTAN ROADTELEPHONE:
(442) 278-1004
CITY:VALLEY CENTERSTATE: CAZIP CODE:
92082
CAPACITY: 6CENSUS: 5DATE:
09/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:11 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
01:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 09/12/25 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required visit annual inspection. LPA was greeted and granted entry by Caregiver Diosdado Delena where LPA explained the purpose of the visit. The administrator Jose Ramirez arrived shortly after LPAs arrival. At the time of the visit there was (1) staff and (4) residents present. LPA conducted a tour of the interior and exterior and observed the following: The governing body is in good standing and the facility annual fees have been paid.
The facility was observed to be free of any obstructions. LPA conducted a review of contact information and verified, and that no changes are needed at this time. LPA obtained a copy of updated liability insurance for the facility file at the regional office. The facility food supply was observed to be adequate, as there was a 2 day supply of perishable and 7 day supply of non perishable food items. LPA observed for there to be expired mustard and barbecue sauce in the storage pantry, that were discarded during LPAs visit. Therefore no deficiency was cited. The medications are stored in a locked cabinet, that is stored in the hallway heading to the kitchen. There are no known guns or ammunition, or pools or bodies of water on the premises. LPA observed for there to be three (3) medications requiring refrigeration inside the refrigerator. The administrator purchased a medication lock box during today's visit, it will be delivered on 09/15/25. The facility is conducting drills on a quarterly basis, the last drill was conducted on 08/07/25. The water temperature was unable to be checked during today's visit as both restrooms were occupied continuously throughout LPAs visit. LPA conducted a file review on both staff and resident files. The administrator Raymond Ramirez, Administrator certification was observed to be valid and expires on 10/21/25. Staff were observed to have have criminal record clearance and to be associated to the facility. The resident files were observed to have medical assessments and appraisals. The smoke and carbon monoxide detectors were tested and were found to be operable. An exit interview was conducted and a copy of this report was reviewed and provided to administrator Ricky Ramirez.
NAME OF LICENSING PROGRAM MANAGER: Carolyn Tuba
NAME OF LICENSING PROGRAM ANALYST: Javina George
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2025
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 2
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)
Page: 2 of 2