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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881357
Report Date: 09/29/2026
Date Signed: 09/29/2026 02:00:47 PM

Document Has Been Signed on 09/29/2026 02:00 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:ST. JEANNE CARE HOME LLCFACILITY NUMBER:
331881357
ADMINISTRATOR/
DIRECTOR:		DERAMAS, MIRAFEFACILITY TYPE:
740
ADDRESS:10225 BONITA AVETELEPHONE:
(707) 704-4400
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY: 6CENSUS: 5DATE:
09/29/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:03 AM
MET WITH:Mirafe Deramas, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Yolanda Delgado and Frank Nguyen arrived unannounced to conduct an annual inspection. Upon arrival LPAs was greeted by facility staff and granted entry by Mirafe Deramas. LPAs began inspection with introduction, visit purpose and provided the Administrator with LPA identification and business card.

Resident record review began- Three (3) records were reviewed. LPAs reviewed for admission agreement, medical assessment-2 not current and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility has not met documentation requirements.

Employee records review began- Two (2) records were reviewed. LPAs reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, training verification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and current 10/22/2027.



Physical Plant and Safety of Environment/Operational Requirements- LPAs toured the facility inside and outside. The facility is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 113.0 degrees F.
(Continued on LIC809, Page 2)
Anthony Perez
Yolanda Delgado
DATE: 09/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2026
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
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ST. JEANNE CARE HOME LLC
FACILITY NUMBER: 331881357
VISIT DATE: 09/29/2026
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(Continued from LIC809, Page 1)

Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in an area. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. LPAs verified there is a telephone working at this location.

Food Service- Food supply meets the one-week supply of nonperishable and 2-day supply of perishables food on hand. A menu is posted; foods are dated to assure safety. Food prep areas are clean and organized.

LPA made observations throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation, and the structure remains unchanged according to the approved floor plan; however exterior building was observed for private residence and building permit was requested and not provided. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguisher are tested or replaced annually and were last done on 06/19/2026. The facility is conducting emergency disaster drills.

Based on the information received during this visit today, the following two (2) deficiencies is being cited per Title 22, Division 6 of The California Code of Regulations.

This report, LIC809D, LIC811 and Appeal Rights was reviewed with Mirafe Deramas and a copy provided at the time of the exit interview.

LPAs requested an updated facility sketch to reflect the two (2) exterior buildings observed and is due by: October 13, 2026
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Yolanda Delgado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/29/2026 02:00 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 09/29/2026 at 01:30 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: ST. JEANNE CARE HOME LLC
FACILITY NUMBER: 331881357

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
(a) Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs Delgado and Nguyen observation and interview, the licensee did not comply with the section cited above in exterior building for Administrator private residence permit was requested and not provided which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2026
Plan of Correction
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Licensee will email copy of building permit to LPA by POC due date.
Type B
Section Cited
CCR
87458(c)(6)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (6) Cognitive conditions, such as MCI and major NCD as defined in Section 87101, Definitions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, interview, record review)], the licensee did not comply with the section cited above in current Medical Assessment were requested and not provided for Residents #1 and Resident #2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2026
Plan of Correction
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Licensee will obtain current Medical Assessments for R#1 and R#2 and email copies to LPA 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.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Yolanda Delgado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2026


LIC809 (FAS) - (06/04)
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