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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881724
Report Date: 09/29/2026
Date Signed: 09/29/2026 03:07:01 PM

Document Has Been Signed on 09/29/2026 03:07 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:LUNA ASSISTED LIVINGFACILITY NUMBER:
331881724
ADMINISTRATOR/
DIRECTOR:		MAMYAN, NARINEFACILITY TYPE:
740
ADDRESS:70603 INDEPENDENT CIRCLETELEPHONE:
(818) 641-9222
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY: 6CENSUS: 6DATE:
09/29/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Michle Tjanbra Care giverTIME VISIT/
INSPECTION COMPLETED:
03:45 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 September 29, 2026 Licensing Program Analyst (LPA) Toni Nwala conducted an unannounced visit to conduct an annual inspection. LPA met with Care giver Michle Tjanbra for a Residential Care Facility for the Elderly (RCFE) with a capacity of six (6) residents. The facility is a six (6) bedroom, four (4) bath home. There are kitchen/dining area, one (1) living room area, a laundry room, and a fenced swimming pool in backyard with locked gate. The facility does not contain firearms or ammunition. LPA toured the interior and exterior areas of the facility. The following were inspected:

All bedrooms have the required bedding and furniture, night-stands, dressers, chairs, lighting, and emergency lighting. The bathroom appliances were operating in safe and sanitary condition. The bathrooms have non-slip floors and grab bars. Utensils and dishware are in good repair and ready for client use. Kitchen appliances and counter-top were free of debris and in good repair. The knives and sharp objects were in kitchen cabinet. LPA observed a knife and a pair of scissors sitting out next to clean dishes. The water temperature was measured to be 107.8 degrees F. There is adequate seating in the common areas. Resident and staff files stored in a locked cabinet located in the living room. LPA observed medication cabinet to be unlocked and accessible to residents .

The facility keep the detergents and cleaning chemicals in cabinets located in the laundry room, LPA observe laundry room to be unlocked and accessible to residents. An adequate supply of clean linens and hygiene supplies for the residents were readily available at the facility. There are one (1) charged fire extinguishers in the facility. Continued on LIC809-C....
Anthony Perez
Toni Nwala
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)
Page: 2 of 4
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: LUNA ASSISTED LIVING
FACILITY NUMBER: 331881724
VISIT DATE: 09/29/2026
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
26
27
28
29
30
31
32
 LPA observed operating smoke detectors and carbon monoxide alarms in the facility. LPA observed required postings including the visitation policies, emergency/disaster plans, complaint procedures, and personal rights.

During LPA visit, LPA observed that the physical plant is clean and in good repair, , LPA issued two (2) Type A deficiency under Title 22 regulations for 87309a and 87465(h)2

An exit interview was conducted, and this report was discussed and provided to Care giver
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Toni Nwala
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 03:07 PM - It Cannot Be Edited


Created By: Toni Nwala On 09/29/2026 at 02:53 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: LUNA ASSISTED LIVING
FACILITY NUMBER: 331881724

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309a


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation interview record review, the licensee did not comply with the section cited above in sharps and cleaning supplies were locked and securedwhich poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2026
Plan of Correction
1
2
3
4
Lincesee stateed they train staff to keep sharps and cleaning supplies locked and secured.
Type A
Section Cited
CCR
87465(h)a


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation interview record review, the licensee did not comply with the section cited above in the medication cabinet was left unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2026
Plan of Correction
1
2
3
4
Lincesee stated they will retain staff on the importance of keeping the medication cabinate locked.
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:
Toni Nwala
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)
Page: 4 of 4