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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426756
Report Date: 09/02/2026
Date Signed: 09/02/2026 03:24:47 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/02/2026 03:24 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CARING TEAM HOME CAREFACILITY NUMBER:
366426756
ADMINISTRATOR/
DIRECTOR:		CLEMONS, NORAFACILITY TYPE:
740
ADDRESS:9736 11TH AVE.TELEPHONE:
(760) 998-2108
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 6CENSUS: 6DATE:
09/02/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:05 PM
MET WITH:Nora ClemonsTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Nora Clemons, Administrator, and was granted entry to the facility. The facility is a Residential Care Facility for Elderly (RCFE) with a license capacity of (6) non-ambulatory, and a current census of (6) residents. LPA conducted an inspection of facility, which included, but was not limited to, the following:

Operation/Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pool or similar bodies of water. The facility has sufficient indoor and outdoor space for resident activities. The facility is maintained at a temperature of 76 degrees fahrenheit (F). Five (5) Resident bedrooms were furnished with beds, bed linen, night stands, chairs, storage space, and sufficient lighting. Two (2) resident bathrooms were maintained clean and bathroom equipment were working properly. The hot water temperatures in the bathrooms measured at 115 and 119 degrees (F). The facility is equipped with smoke/carbon monoxide alarms, fully charged fire extinguishers, covered fireplace, first aid kit with manual, emergency lights and water, laundry equipment, and telephone service. Posters such as personal rights, the Community Care Licensing complaint poster, Ombudsman poster, emergency telephone numbers, and facility license were posted in common area. The Administrator was informed that the facility's annual licensing fees are due on September 14, 2026.

Karen Clemons
Magda Malcore
DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2026
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: CARING TEAM HOME CARE
FACILITY NUMBER: 366426756
VISIT DATE: 09/02/2026
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Food Service: Kitchen and dining areas were maintained cleaned. Facility maintains a week of non-perishable and a two-day of perishable food supply for residents in care.

Medications: Facility maintains records of resident's centrally stored medications and medications are stored in a locked cabinet.

Record Review: LPA review of resident files reveals, resident #1 (R1) did not have documentation of a reappraisal conducted within 12 months on file. LPA review of staff files reveals, that the following documentation was not maintained in staff#1(S1) and staff#2 (S2) personnel files: a health screening with chest X-ray or intradermal results, and record of past employment history/experience.

Based on LPA observations, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations (CCR).

An exit interview was conducted where reports (LIC809, LIC809-C, LIC809-D) and correction plans were discussed. Copies of the reports with appeal rights were provided to Administrator Clemons at the conclusion of the visit.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Magda Malcore
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/02/2026 03:24 PM - It Cannot Be Edited


Created By: Magda Malcore On 09/02/2026 at 02:32 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: CARING TEAM HOME CARE
FACILITY NUMBER: 366426756

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2026
Section Cited
CCR
87463(a)

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87463(a)The pre-admission appraisal...shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition...and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal..this requirement is not met as evidenced by:
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The Administrator/Licensee shall provide to the licensing agency documentation of a current reappraisal for R1 by POC due date.
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The Licensee did not comply with the section cited above by resident #1 (R1) did not have documentation of a reappraisal conducted within 12 months on file, this poses a potential health, safety, and person rights risks to persons in care.
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Type B
09/16/2026
Section Cited
CCR87412(a)(7)

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87412(a)(7)The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:(7)Past experience, including types of employment and former employers; this requirement is not met as evidenced by:
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The Licensee/Administrator shall provided to the Licensing Agency documentation of personnel record containing employment history/experience for staff#1 and staff #2 by POC due.
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The licensee did not comply with the section cited above by not maintaining record of past employment history/experience for Staff#1 (S1) and Staff#2 (S2); which poses a potential health, safety, and 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:
Magda Malcore
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/02/2026 03:24 PM - It Cannot Be Edited


Created By: Magda Malcore On 09/02/2026 at 02:50 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: CARING TEAM HOME CARE
FACILITY NUMBER: 366426756

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2026
Section Cited
CCR
87411(f)

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87411(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician...this requirement is not met as evidenced by:
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The Licensee/Administrator shall provide to the Licensing agency documentation of health screening with a chest x-ray or an intradermal test results for S1 and S2 by POC due date.
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The Licensee did not comply with the section cited above by not maintaining on file documentation of a health screening and a chest x-ray or intradermal test results for staff#1(S1) and staff#2 (S1); which poses a potential health, safety, and 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:
Magda Malcore
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2026


LIC809 (FAS) - (06/04)
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