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Type of visit: Case Management - Other

Licensing Program Analyst (LPA) LaVette Farlow arrived at the facility unannounced to conduct a Case Management Visit. This case management visit is in response to requested documents from Licensee, Nitin Vermani. LPA was greeted and granted entry by House Manager, Sandy Barr. LPA greeted Sandy and stated purpose of the visit. LPA asked Sandy to notify Nitin of LPA arrival. LPA Farlow made several request for the LIC500, LIC309, and LIC401. LPA requested these documents via telephone, and via text message on July 13, 2026, July 16, 2026, and August 10, 2026. During today's visit, LPA received the LIC500, and Licensee stated he would send the remaining document before the close of business today. LPA conducted a tour of the facility, no imminent health and/or safety concerns observed at the time of visit. Due to Licensing agency making several attempts to retrieve requested documents and licensee failure to comply a deficiency will be cited. Failure to correct the Licensing Report within a specified length of time would result in a civil penalty. Failure to make the correction by the date specified, will result in a civil penalty of $100 per violation per day until the violation is corrected. A Deficiency was issued during this visit. An exit interview was conducted where this report LIC809 and LIC809D was reviewed, discussed and provided to House Manager, Sandy Barr.the state’s words, verbatim · CDSS document, Aug 13, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87755(c) · Plan of correction due date: Aug 14, 2026

87755 Inspection Authority of the Licensing Agency (c) The licensing agency shall... authority to inspect, audit, and copy... facility records upon demand during... Records ... if necessary for copying. Removal of records shall be subject to the requirements..This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above by not by the requested documents to CCLD. LPA made several request via telephone call and text messages which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 13, 2026

Plan of correction: Licensee agrees to provide the requested document to LPA by (12) noon on 8/14/2026 via email or directly to CCLD San Bernardino R.O.

Type of visit: Required - 1 Year

On 7/16/2026 at 11:44 AM, Licensing Program Analyst (LPA) LaVette Farlow arrived unannounced to conduct the required annual visit to the facility. LPA met with House Manager Sandy Barr, and introduced self and stated purpose of the visit. LPA was informed the current census is five (5) two (2) residents were present during the visit two (2) resident were at InnovAge Day Program, and one (1) resident was visiting with family. The facility has 4 bedrooms, 2 1/2 bathrooms, 1 staff bedroom, kitchen, dining area, family room, living room, washer and dry in the garage, attached garage, and backyard. LPA completed a walk through of facility, review of records, and medication. Physical Plant: 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 76 degrees Fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. During the inspection LPA observed cleaning supplies under the bathroom sink in the staff bathroom by the kitchen. The cabinet was unlocked and not secured with chemical spray bottle and can of Ajax unsecured. A Deficiency cited. The water temperature was tested and measured at 115.5, 107.1 and 113.3 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms and charged fire extinguisher, the last fire extinguisher inspection was conducted 7/17/2025. Posters such as; the personal rights, CCL complaint poster and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept secure and inaccessible to residents. There was a designated storage space for residents/staff files. Medications and first aid kit were observed secure and inaccessible to residents. The facility has emergency food and emergency to go backpacks for residents in care. There are no firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a wide variety of food available for residents. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a wide variety of food available for residents. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed. Yards/Outside: LPA observed the patio with plenty of tables, chairs and umbrellas for the residents in care. The backyard has a side gates with self-latching handle on the left and right side of the house that leads into the backyard. All outdoor pathways were free of obstructions. Record Review: LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. LPA reviewed three (3) residents files for admissions agreements, pre-admissions appraisals, physician's reports, and care plans. LPA observed that all files were current and appeared to be maintained. No discrepancies. LPA review the facility files for LIC 500 (Staff Roster) LIC 9020 (Residents Roster), Emergency Disaster Plan, LIC 9282 (Infection Control Plan Annual Report), and Fire Drill. LPA observed the file were maintained and no discrepancies found. LPA conducted a medication audit for three (3) residents. Two (2) out of three (3) residents had medications that were on the MARs but not on the Centrally Stored Medication Sheet. A Deficiency cited. Based on the observations made during today’s visit, two deficiencies were cited, per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809), (LIC809C), (LIC809D) and appear rights were discussed and provided to House Manager, Sandy Barr at the end of the visit.the state’s words, verbatim · CDSS document, Jul 16, 2026

Allegation investigated: Staff consume liquor while on shift. Staff do not have fingerprint clearance. Staff lock facility doors to prevent residents from leaving. Staff insert suppositories to residents in care. Staff did not complete required trainings. Staff facility records are falsified. Staff did not maintain resident records. Residents are not provided proper food service.

Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to investigate and deliver findings on the allegations listed above. LPA met with House Manager Sandy Barr and explained the purpose of the visit. The investigation consisted of staff interviews, resident interviews, record review and facility tour. For the allegation, Staff consume liquor while on shift. During staff interviews, 3 out of the 3 staff stated that they do not consume liquor on the shift. During resident interviews 3 out of the 3 residents stated they have not witnessed a staff drink consuming liquor on the shift. For the allegation, Staff do not have fingerprint clearance. During staff interviews 3 out of the 3 staff stated that all staff memebers have a fingerprint clearance. Based on record review, LPA observed all staff memebers had a criminal record clearance. Unsubstantiated For the allegation, Staff lock facility doors to prevent residents from leaving. During staff interviews 3 out of the 3 staff stated they do not lock the facility to prevent residents from leaving. During resident interviews, 3 out of the residents stated they are not locked inside the facility. During facility tour, LPA Rico did not observe any locks from facility exits. For the allegation, Staff insert suppositories to residents in care. During staff interviews 3 out of the 3 staff stated they do not have insert suppositories to residents. For the allegation, Staff did not complete required training. During staff interviews 3 out of the 3 staff stated they have completed their required training. Based on record reviews, LPA Rico observed staff have completed their training. For the allegation, Staff facility records are falsified. During staff interviews, 3 out of the 3 staff stated they have not falsified facility records. For the allegation, Staff did not maintain resident records. During staff interviews 3 out of the 3 staff stated residents records are maintained inside the facility and locked. During facility tour, LPA observed resident records were kept inside the facility and locked. For the allegation, Residents are not provided proper food service. During staff interviews, 3 out of the 3 staff stated proper food service is provided to the residents. During resident interviews, 3 out of the 3 residents had no complaints regarding their food. In addition, LPA observed the facility had proper food and a menu for each meal. Based on the evidence found during the investigation, the eight(8) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to House Manager Sandy Barr. For the allegation, Staff did not provide adequate medication assistance to residents in care. During staff interviews 3 out of the 3 staff stated they follow resident’s medication order and document on resident’s MAR. In addition, 3 out of the 3 staff stated medication is provided to all residents. During resident interviews, 3 out of the 3 residents stated they received their medication. For the allegation, Staff refuse to call an ambulance for residents in care. During staff interviews, 3 out of the staff stated they never denied an ambulance for a resident. During resident interviews, 3 out of the 3 residents stated staff have not refused to call an ambulance. For the allegation, Staff threatened residents in care. During staff interviews, 3 out of the 3 staff interviews stated they have not threatened a resident. During residents’ interviews, 3 out of the 3 residents stated they have not been threatened by staff. For the allegation, Staff did not ensure sufficient food items were available at the facility for residents in care. During staff interviews, 3 out of the 3 staff stated the facility has sufficient food available for the residents. Based on facility tour, LPA observed the facility has sufficient food available for residents. For the allegation, Staff did not prevent residents from engaging in inappropriate interactions. During staff interviews, 3 out of the 3 staff stated no residents have engaged in inappropriate interactions. During residents’ interviews, 3 out of the 3 residents stated they have not engaged in inappropriate interactions. Based on the evidence found during the investigation, the seven (7) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to House Manager Sandy Barr. For the allegation, Centrally stored medications are accessible to residents in care. During staff interviews 3 out of the 3 staff stated medication is kept locked and inaccessible to residents. During facility tour, LPA observed medications locked inside a cabinet and inaccessible to residents. For the allegation, Staff do not have a fire evacuation plan at the facility. During staff interviews, 3 out of the 3 staff stated the facility has fire evacuation plan posted on the facility hallway and emergency supplies/ food is in the garage. During facility tour, LPA observed the facility had an updated disaster plan with the evacuation location, LPA also observed emergency food/supplies readily available. For the allegation, Staff do not have an infection control plan at the facility. During staff interviews, 3 out of the 3 staff stated the facility has an infection control plan. During record review, LPA Rico observed the facility had an updated infection control plan. For the allegation, Staff are not following reporting requirements. During staff interviews 3 out of the 3 staff stated they follow reporting requirements. For the allegation, Staff left residents unattended. During staff interviews, 3 out of the 3 staff do not leave residents unattended. During resident interviews, 3 out of the 3 staff stated they have not been unattended inside the facility. Based on the evidence found during the investigation, the seven (7) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to House Manager Sandy Barr.the state’s words, verbatim · CDSS document, Dec 2, 2025 · control 56-AS-20241120151735

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) LaVette Farlow arrived unannounced to conduct the required annual visit to the facility. LPA met with House Manager Sandy Barr, and introduced self and stated purpose of the visit. LPA was informed that there was 4 client home and 2 in Innovage day program. The facility has 4 bedrooms, 2 1/2 bathrooms, 1 staff bedroom, kitchen, dining area, family room, living room, washer and dry in the garage, attached garage, and backyard. LPA completed a walk through of facility, review of records, and medication. Physical Plant: 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 76 degrees Fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 105.6, 104.6 and 108.0 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms and charged fire extinguisher, the last fire extinguisher inspection was conducted 7/2025. Posters such as; the personal rights, CCL complaint poster and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept in secure and inaccessible to clients. There was a designated storage space for client/staff files. Medications and first aid kit were observed secure and inaccessible to clients. The facility has emergency food and emergency to go backpacks for clients in care. There are no firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care. Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a wide variety of food available for clients. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed. Yards/Outside: LPA observed shaded area with table and chairs on patio, a side gate with self-latching handle on the left and right side of the house that leads into the backyard. All outdoor pathways were free of obstructions. Record Review: LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. LPA reviewed three (3) clients files for admissions agreements, pre-admissions appraisals, physician's reports, and care plans. LPA observed that all files were current and appeared to be maintained. No discrepancies. LPA review the facility files for Infection Control plan, LIC 500 (Staff Roster) LIC 9020 (Client Roster), Emergency Disaster Plan, LIC 9282 (Infection Control Plan Annual Report), and Fire Drill. LPA observed the file were maintained and no discrepancies found. Based on the observations made during today’s visit, no deficiencies were cited, per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809), and (LIC809C) was discussed and provided to House Manager, Sandy Barr at the end of the visit.the state’s words, verbatim · CDSS document, Sep 9, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced visit to this facility to initiate an investigation on complaint 56-AS-20241120151735. LPA met with Caregiver, Elva Valdivia. During the visit, LPA conducted observations, interviews with staff, and did a walk-through of the facility. LPA found the following issue: LPA was not able to have access to records since lead staff left out of the state due to an emergency and took key with self. This poses a potential health and safety risk to residents in care. Refer to LIC 809D for deficiencies cited. An exit interview was conducted where this report, LIC809D, and appeal rights were discussed with and provided to caregiver, Elva Valdivia.the state’s words, verbatim · CDSS document, Nov 22, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87755(c) · Plan of correction due date: Nov 27, 2024

87755(c) Inspection Authority of the Licensing (c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal....and 87508(b).This requirement is not met as evidenced by: Based on observation, and interview, the licensee did not comply with the section cited above by not providing access to the licensing agency to inspect, audit, and copy which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 22, 2024

Plan of correction: Licensee stated that he will make duplicate keys to the filing cabinets for records to be available upon request. Licensee stated that he will submit a statement of understanding to LPA via email by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) LaVette Farlow and Bernadette Allen arrived unannounced to conduct the required annual visit to the facility. LPAs met with Manager Sandy Barr, and introduced themselves and stated purpose of the visit. LPAs were informed that there was 3 client home and 3 in Innovage day program. The facility has 4 bedrooms, 2 1/2 bathrooms, 1 staff bedroom, kitchen, dining area, family room, living room, washer and dry in the garage, attached garage, and backyard. LPAs completed a walk through of facility, review of records, and medication. Physical Plant: 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 fahrenheit. LPAs inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPAs inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 112.1 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms and charged fire extinguisher, the last fire extinguisher inspection was conducted 7/2024. Posters such as; the personal rights, CCL complaint poster and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept in secure and inaccessible to clients. There was a designated storage space for client/staff files. Medications and first aid kit were observed secure and inaccessible to clients. The facility did not have emergency kits in the facility for clients in care. A technical advisory was issued. There are no firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care. Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a wide variety of food available for clients. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed. Yards/Outside: LPAs observed shaded area with table and chairs on patio, a side gate with self-latching handle on the left and right side of the house that leads into the backyard. All outdoor pathways were free of obstructions. Record Review: LPAs reviewed Administrator and staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. LPAs reviewed client files for admissions agreements, pre-admissions appraisals, physician's reports, and care plans. LPAs observed that the manager in the facility was not associated to the facility. A technical advisory was issued. No deficiencies were cited during this visit, two (2) technical advisories were issued. An exit interview was conducted where this report LIC809, LIC809C, LIC9102TA and appeal rights were discussed and copies were provided to the Manager Sandy Barr at the end of the visit.the state’s words, verbatim · CDSS document, Oct 9, 2024