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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530364
Report Date: 09/15/2026
Date Signed: 09/15/2026 04:14:58 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/15/2026 04:14 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:BIRCH RESIDENCEFACILITY NUMBER:
365530364
ADMINISTRATOR/
DIRECTOR:		ANDERSON, DEANFACILITY TYPE:
740
ADDRESS:25185 BIRCH STREETTELEPHONE:
(909) 754-0377
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY: 6CENSUS: 3DATE:
09/15/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Caregiver Luz AndersonTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarina Ramirez made an unannounced visit to the facility to conduct a required annual inspection. LPA met with caregiver Luz Anderson, and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (6), a current census of (3). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility has a swimming pool that is enclosed and kept locked. The facility has sufficient lighting and is maintained at a comfortable temperature. The facility has sufficient indoor and outdoor space for resident activities. The facility is equipped with operating smoke detectors/carbon monoxide alarms, working laundry equipment, and telephone service. Resident’s showers, toilets, and hand washing areas were operating properly. The hot water temperature in three (3) resident bathrooms measured between 107.6 to 124 degrees F, technical issued. Three (3) resident’s bedrooms had beds, bed linen, chairs, dresser, storage space and sufficient lighting. The facility has sufficient linens, towels, and personal hygiene items for residents. The facility has posted in a common area, facility license, facility sketch, emergency telephone numbers, CCLD complaint poster, and Ombudsman poster.

Food Service: Facility kitchen and dining area are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. Sharps and chemicals were kept locked and inaccessible to residents in care.

Continuation on LIC – 809C:
Karen Clemons
Sarina Ramirez
DATE: 09/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2026
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BIRCH RESIDENCE
FACILITY NUMBER: 365530364
VISIT DATE: 09/15/2026
NARRATIVE
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Care & Supervision: Facility has 24-hour/7days a week care staff. Facility staff do not CPR/first aid certificates, deficiency issued. Staff #1 (S1) was not associated to the facility through Guardian, deficiency issued.

Medical Related Services: Resident’s medications are labeled and centrally stored in a locked cabinet. Medication is administered as prescribed.

Record Review: Two (2) Staff files reviewed were observed to be incomplete, deficiency issued. Three (3) Resident files reviewed were observed to be incomplete, Resident #1 (R1) has a missing Admission Agreement, R1,R2, R3 had missing needs and service plans, R3 had a medical assessment from another facility, deficiency issued. The facility did not have a liability insurance available for review, deficiency issued.

Based on observations, interviews, and record review deficiencies and technical assistance were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report LIC 809/C along with LIC 809D, LIC 811, LIC 9102, and appeal rights were discussed and provided to Caregiver Luz Anderson at the conclusion of the visit .

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Sarina Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2026
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 09/15/2026 04:14 PM - It Cannot Be Edited


Created By: Sarina Ramirez On 09/15/2026 at 02:20 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: BIRCH RESIDENCE
FACILITY NUMBER: 365530364

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/22/2026
Section Cited
CCR
87506(b)(15)

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87506 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 was not met by:
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Licensee will create an admission agreement for (R1) and Pre appraisals for R1, R2, R3 and provide proof to LPA by POC due date. Licensee will also review regulation and provide proof of understanding to LPA by POC due date.
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The licensee did not comply with the section cited above by not having admission agreements for R1, pre admission appraisal for R1,R2,R3, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
09/30/2026
Section Cited
HSC1569.605

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On and after July 1, 2015, all residential care facilities for the elderly... shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000)... the licensee or its employees.This requirement is not met as evidenced by:
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Licensee will purchase liability insurance and provide proof to LPA by POC due date
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the licensee did not comply with the section cited above by not having liability insurance which poses/posed a potential health, safety or personal rights risk to persons in care.
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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:
Sarina Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2026


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 09/15/2026 04:14 PM - It Cannot Be Edited


Created By: Sarina Ramirez On 09/15/2026 at 02:45 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: BIRCH RESIDENCE
FACILITY NUMBER: 365530364

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2026
Section Cited
CCR
87458(a)

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87458 Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional... to be kept in the resident's record.This requirement is not met as evidenced by:
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Licensee will obtain a new Medical Assessment (LIC 602A) for R#3 and provide proof to LPA by POC due date.
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The licensee did not comply with the section cited above by having a medical assessment from another facility (ExcelCare) which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
09/22/2026
Section Cited
HSC1569.618(c)(3)

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(c)The facility shall employ, and the administrator shall schedule... (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times.This requirement is not met as evidenced by:
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Licensee will have S1 obtain a first aid/CPR certificate by recognized provider (American Heart Association, American Red Cross, CPR Test Center, or National CPR Foundation) and provide proof to LPA by POC due date.
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The licensee did not comply with the section cited above, although Staff #1 (S1) has training of completion for first aid training, S1 did not have a CPR/first aid certificate
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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:
Sarina Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 09/15/2026 04:14 PM - It Cannot Be Edited


Created By: Sarina Ramirez On 09/15/2026 at 03:07 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: BIRCH RESIDENCE
FACILITY NUMBER: 365530364

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2026
Section Cited
HSC
1569.695(e)(2)

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(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident. This requirement is not met as evidenced by:
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Licensee will create LIC 625 needs and service plans for R1,R2, R3 and provide proof to LPA by POC due date
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 The licensee did not comply with the section cited above by not having (LIC 625) Needs and Service plans for resident #1, #2, #3 which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
09/18/2026
Section Cited
CCR87411

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87411 Personnel Requirements - General
(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)...This requirement was not met as evidenced by:
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Licensee will associate S1 to the facility and notify/provide proof to LPA by POC due date
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 The licensee did not comply with the section cited above by not associating Staff #1 (S1) to the facility through guardian which poses/posed a potential health, safety or personal rights risk to persons in care.
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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:
Sarina Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2026


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 09/15/2026 04:14 PM - It Cannot Be Edited


Created By: Sarina Ramirez On 09/15/2026 at 03:54 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: BIRCH RESIDENCE
FACILITY NUMBER: 365530364

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2026
Section Cited
CCR
87411(d)

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(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by:
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Licensee will provide training and create a log for staff #2 (S2) and provide proof to LPA by POC due date
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 The licensee did not comply with the section cited above not having a training log for staff #2 (S2) which poses/posed a potential health, safety or personal rights risk to persons in care.
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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:
Sarina Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2026


LIC809 (FAS) - (06/04)
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