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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423880
Report Date: 09/23/2026
Date Signed: 09/23/2026 10:17:48 AM

Document Has Been Signed on 09/23/2026 10:17 AM - 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:CORONA RCFEFACILITY NUMBER:
336423880
ADMINISTRATOR/
DIRECTOR:		JENNIFER D. MONTGOMERYFACILITY TYPE:
740
ADDRESS:2600 SOUTH MAIN STREETTELEPHONE:
(951) 736-4900
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY: 49CENSUS: 27DATE:
09/23/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Assistant Administrator - Christine GarnicaTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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On 9/23/2026, Licensing Program Analyst, Mary Rico and Licensing Program Analyst Matthew Aguilar conducted a case management visit to provide licensee with a report following the Department’s investigation of the death of Resident #1 (R1). Department investigation consisted of interviews and review of records for R1.

On January 29, 2026, facility reported that an accident occurred in front of the facility involving Resident #1 (R1). Corona Police Department later informed the facility that R1 was struck by a vehicle while crossing the street and pronounced deceased at the scene.

Evidence shows on January 29, 2026, R1 left the facility without supervision and was subsequently struck by a vehicle. According to R1’s Physician Report, R1 was not permitted to leave the facility unsupervised. Medical records show that R1 had dementia, a history of 5150 holds, and repeated missed medications.

On January 26, 2026, R1’s hospital discharge instructions indicate R1 should be placed in a memory care facility with adequate supervision. The facility’s current plan of operation indicates the facility shall not accept or retain residents determined by a physician to have a primary diagnosis of mental disorder unrelated to dementia. Despite these instructions, R1 was readmitted to the facility without any additional supervision. The administrator acknowledged that R1 was not allowed to leave unsupervised yet continued to permit R1 to exit the facility freely. Evidence shows the facility staff failed to follow the care requirements outlined in R1’s Physician Report and hospital discharge instructions. Despite being fully aware of R1’s diagnoses and behavioral instability, facility staff did not implement monitoring, supervision, or preventive measures to ensure R1’s safety.

Efren Malagon
Mary Rico
DATE: 09/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2026
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: CORONA RCFE
FACILITY NUMBER: 336423880
VISIT DATE: 09/23/2026
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Based on the evidence R1 died due to facility not providing proper care and supervision there was preponderance of the evidence and the standard has been met.

Licensee is cited per violation of Title 22 Regulations. In addition, this violation posed an immediate Health and Safety risk to residents in care. An immediate civil penalty of $500 is being assessed. The licensee was also informed that a civil penalty may be assessed based on health and Safety Code 1569.49(f).

A copy of this report was provided to Assistant Administrator Christine Garnica. Along with a copy of appeal rights. The Assistant Administrator refused to sign the report.

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Mary Rico
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/23/2026 10:17 AM - It Cannot Be Edited


Created By: Mary Rico On 09/23/2026 at 08:55 AM
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: CORONA RCFE
FACILITY NUMBER: 336423880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/24/2026
Section Cited
HSC
1569.269(a)(6)

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H&S: 1569.269(a)(6) Enumerated rights; severability: Residents of residential care facilities for the elderly shall have all of the following rights: To care, supervision, and..staff ..sufficient.. qualifications..
competency to meet their needs.This requirement was not met as evidenced by:
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The Licensee shall submit to the licensing agency by POC due date, a plan of preventative measures the facility will take to ensure the health and safety of residents who require supervision.
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Facility staff were not competent in meeting R1 needs. Facility staff failed to properly supervise R1. Following R1 leaving facility premises on January 29, 2026, R1 was struck by a vehicle and killed while attempting to cross the street. This posed an immediate risk to residents in care.
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POC 9/24/2026

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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.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Mary Rico
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2026


LIC809 (FAS) - (06/04)
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