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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530303
Report Date: 09/04/2026
Date Signed: 09/04/2026 02:00:15 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/04/2026 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:TEENEE'S HOMEFACILITY NUMBER:
365530303
ADMINISTRATOR/
DIRECTOR:		PARCHEJO, JERRYFACILITY TYPE:
740
ADDRESS:801 S WISTERIA AVENUETELEPHONE:
(818) 484-0061
CITY:BLOOMINGTONSTATE: CAZIP CODE:
92316
CAPACITY: 4CENSUS: 2DATE:
09/04/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:25 AM
MET WITH:Caregiver, Iluminada CulabaTIME VISIT/
INSPECTION COMPLETED:
02:25 PM
NARRATIVE
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On 9/04/2026, Licensing Program Analyst (LPA) E. Conchas conducted an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Caregiver Iluminada Culaba and was granted entry to the facility. Caregiver Iluminada assisted LPA with the tour at the facility during the visit. At the time of the visit there were two staff present.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for a capacity of four (4). Three (3) non-ambulatory clients and one (1) bedridden. The facility is vendorized by Inland Regional Center (IRC). The facility has five (5) bedrooms, two (2) bathrooms, a kitchen, dining area, living room, backyard with shaded seating area, and attached garage with laundry access inside locked.

The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees Fahrenheit. LPA observed sufficient furniture and lighting throughout the facility.

LPA inspected resident bedrooms in which are equipped with the required furniture and sufficient lighting. The bathrooms were clean and the appliances were operating in safe and sanitary condition. The water temperature was measured around 111 degrees Fahrenheit. LPA observed a linen closet containing extra sufficient linen in the hallway. The Kitchen was observed to have appliances and counter top free of debris and in good repair. LPA observed sufficient non-perishable and perishable food supply for the residents in care. There was a designated dining area for clients for meals. There was a designated locked and secured drawer where sharps and chemicals are stored. LPA observed the staff schedule, Meal menu and activities calendar on display. LPA observed there is adequate seating in the common areas.

Continue to LIC809-C

Karen Clemons
Edith Conchas
DATE: 09/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2026
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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Document Has Been Signed on 09/04/2026 02:00 PM - It Cannot Be Edited


Created By: Edith Conchas On 09/04/2026 at 01:14 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: TEENEE'S HOME
FACILITY NUMBER: 365530303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/05/2026
Section Cited
CCR
87470(c)(1)(D)

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 (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:
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Licensee/ administrator to review the plan and sign and date it and maintain annual reviews. Will send proof to LPA by POC date.
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Based on record review, the administrator did not comply with the section cited above by not signing or dating the plan to show it was reviewed annually with staff which poses a potential health, safety or personal rights risk to persons in care.
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Type B
10/05/2026
Section Cited
CCR87216(1)(a)

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87216 Bonding (a)Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal. This requirement is not met as evidenced by:
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Licensee/ administrator to provide proof of bond to LPA by POC date.
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facility staff were unable to provide proof of a current bond for hadnling clients P&I during the visit.
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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: 09/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2026


LIC809 (FAS) - (06/04)
Page: 3 of 4
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: TEENEE'S HOME
FACILITY NUMBER: 365530303
VISIT DATE: 09/04/2026
NARRATIVE
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The facility has a supply of activities for the clients. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguisher was observed to be inspected and current. LPA observed a complete first aid kit and First Aid Manual. LPA advised obtaining a current First aid Manual approved by the American Red Cross, the American Medical Association or a state federal health agency.

LPA observed a locked closet containing staff, facility, and client files along with client medications. LPA reviewed Facility file for drills, liability insurance, bond, emergency disaster plan and infection control plan. LPA reviewed staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings with Tuberculosis (TB) test result to be complete. LPA observed resident files for admission agreements, updated physician reports, and needs and services plans to be complete. The Medications/Medication Administration Record (MAR) were audited and observed to be administered accurately.

Posters such as Personal Rights, the CCLD complaint poster, labor laws, House rules, Long Term Ombudsman, and the facility sketch were posted in a common area.

The following was observed;

· Infection control plan was not signed or dated to show it was reviewed annually with staff.

· No active bond for safeguarding residents cash resources.

Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. A copy of this report was provided to Caregiver Iluminada Culaba at the conclusion of the visit.

Continue to LIC809-D.

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

DATE: 09/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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