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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336402613
Report Date: 09/18/2026
Date Signed: 09/18/2026 02:59:45 PM

Document Has Been Signed on 09/18/2026 02:59 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:SACRED HEART HOME FOR ELDERLYFACILITY NUMBER:
336402613
ADMINISTRATOR/
DIRECTOR:		TAGUM, NELIA TOLEDOFACILITY TYPE:
740
ADDRESS:291 WEST DALE STREETTELEPHONE:
(951) 845-8978
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY: 6CENSUS: 5DATE:
09/18/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Nelia Tagum, administrator TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) E. Conchas made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Facility Administrator Nelia Tagum and was granted entry to the facility. At the time of the visit there were two (2) staff present, and five (5) residents present. The facility is an eight (8) bedroom, four and a half (4.5) bathroom home, with a kitchen/dining area, living room, and a detached garage. LPA was accompanied by Facility Administrator to conduct a general overall inspection.

The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees F. LPA inspected resident’s bedrooms which are equipped with required furniture, storage space, and sufficient lighting. LPA observed the bathrooms were clean, and appliances were operating appropriately with water temperature measuring between 108-110 degrees F. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors. Posters such as personal rights, the CCL complaint poster, LTCO, facility sketch and administrator certificate were posted in a common area.

LPA observed cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was sufficient non-perishable and perishable food supply sufficient for number of residents in care. Overall, the facility is clean and in good repair.

There was a designated storage space for resident and staff files. LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. Medications are kept inside a filing cabinet inaccessible to residents in care. Medications were audited. Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings.

Continue to LIC809-C

Karen Clemons
Edith Conchas
DATE: 09/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2026
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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Document Has Been Signed on 09/18/2026 02:59 PM - It Cannot Be Edited


Created By: Edith Conchas On 09/18/2026 at 01:43 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: SACRED HEART HOME FOR ELDERLY
FACILITY NUMBER: 336402613

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having any carbon monoxide detectors which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2026
Plan of Correction
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Administrator/ Licensee to immediatly obtain carbon monoxide detectors and maintain them at the facility and will send a image to LPA by POC date and train staff 1.
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:
Edith Conchas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/18/2026 02:59 PM - It Cannot Be Edited


Created By: Edith Conchas On 09/18/2026 at 01:43 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: SACRED HEART HOME FOR ELDERLY
FACILITY NUMBER: 336402613

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having a record of dosages of medication for any of the five residentss which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2026
Plan of Correction
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Licensee to review all of regulation 87456 (a), train staff 1. Create a MAR for each resident and begin recording the dosages for each resident. Send a copy to LPA by POC date.
Type A
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not having a completed file with missing forms for R4, inclduing addmission agreement which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2026
Plan of Correction
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Licensee to complete the admission agreement for R4 and any other incomplete documentation required under regulation 87506.
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:
Edith Conchas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/18/2026 02:59 PM - It Cannot Be Edited


Created By: Edith Conchas On 09/18/2026 at 01:43 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: SACRED HEART HOME FOR ELDERLY
FACILITY NUMBER: 336402613

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)(1)(D)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (D) The licensee shall review the use of infection control procedures in the facility at least annually, if local government public health determines an epidemic outbreak has occurred, or if the review is requested by the local licensing agency.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not reviewing the use of infection control procedures in the facility at least annually and or signing off it was completed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2026
Plan of Correction
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Licensee to reveiw the plan, train staff 1, sign and date to indicate the plan was reviewed
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not reviewing the plan annually and or not signing off it was completed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2026
Plan of Correction
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Licensee to reveiw the plan, train staff 1, sign and date to indicate the plan was reviewed
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:
Edith Conchas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/18/2026 02:59 PM - It Cannot Be Edited


Created By: Edith Conchas On 09/18/2026 at 02:16 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: SACRED HEART HOME FOR ELDERLY
FACILITY NUMBER: 336402613

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review , the licensee did not comply with the section cited above by not having staff 1 complete annual training requirements which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2026
Plan of Correction
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Staff 1 to complete annual training required based on regulation and any additional training required based on the type of clients in care.
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:
Edith Conchas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2026


LIC809 (FAS) - (06/04)
Page: 6 of 7
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: SACRED HEART HOME FOR ELDERLY
FACILITY NUMBER: 336402613
VISIT DATE: 09/18/2026
NARRATIVE
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The following was observed and cited;

· LPA observed the infection control plan where there was no indication of annual update or review.

· LPA observed there was no carbon monoxide detector at the facility.

· Staff 1 did not have any annual training completed.

· LPA observed no MAR for any resident.

· LPA observed Resident 4's file to be incomplete, including missing an admission agreement.

· LPA observed Emergency disaster plan where there was no indication of annual update or review.

Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and will be provided to Facility Administrator Nelia Tagum.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Edith Conchas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2026
LIC809 (FAS) - (06/04)
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