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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530259
Report Date: 06/15/2026
Date Signed: 06/15/2026 05:18:44 PM

Document Has Been Signed on 06/15/2026 05:18 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:HILLS OF SOUTH LANE II, THEFACILITY NUMBER:
365530259
ADMINISTRATOR/
DIRECTOR:		CHAVEZ, REGINAFACILITY TYPE:
740
ADDRESS:12908 SOUTH LANETELEPHONE:
(714) 363-3752
CITY:REDLANDSSTATE: CAZIP CODE:
92373
CAPACITY: 6CENSUS: 3DATE:
06/15/2026
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Marc Zalameda, CaregiverTIME VISIT/
INSPECTION COMPLETED:
05:25 PM
NARRATIVE
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On 06/15/2026, at 2:00PM Licensing Program Analyst (LPA) LaVette Farlow arrived at the facility, unannounced to conduct a Case Management visit. LPA identified herself and met Marc Zalameda and gained access to the facility. LPA attempted to contact Maricel Nepomuceno, Administrator who's licensee is posted in the facility and left a voicemail and Regina Chavez who is listed as the Administrator on CCLD record. Regina's number was not a working number. LPA informed Caregiver Marc that this visit is being conducted to follow up on the facility's compliance with Health & Safety Code Section 1569.38.

Health & Safety Code 1569.38 requires the licensee to post a written notice and the accusation notice received must be posted in a conspicuous location in the facility and shall remain posted until the deficiencies that gave rise to the accusation notice are resolved. During the tour of the facility on 06/15/2026, LPA observed that the accusation and written notice that the facility received was not posted, as required by law, at the front door, near entrance of the facility, kitchen, and inside the facility near the Common Area, and Dining Room.

LPA also, observed a for sale sign in front of the property. LPA inquired to verified the status of the sale and if an eviction notice was issued to responsible parties, or the residents in care. LPA was unable to verify that proper notice was provided. LPA conducted a tour of the facility and the following was observed:

LPA did a health and safety check. LPA observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. LPA observed 3 residents and 2 staff. Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

***Continued on LIC809C***

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2026
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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Document Has Been Signed on 06/15/2026 05:18 PM - It Cannot Be Edited


Created By: Lavette Farlow On 06/15/2026 at 04:21 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: HILLS OF SOUTH LANE II, THE
FACILITY NUMBER: 365530259

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/16/2026
Section Cited
HSC
1569.38(f)

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Health and Safety Code (HSC) 1569.38
Posting of licensing reports; disclosure ... (f)The notice required to be posted pursuant to subdivision (e) shall remain posted until the deficiencies that gave rise to the notice are resolved. This requirement was not met as evidenced by:
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Licensee will post the accusation notice in the conspicuous location and will send a written notice and provide proof regarding the accusation to the resident, residents responsible party if any and long term care ombudsman (LTCO) on plan of correction (POC) due date.
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Based on observation, interview and record review, the Licensee did not comply with the section cited above by not ensuring that the written notice and the accusation notice received were posted in a conspicuous location in the facility and shall remain posted until the
deficiencies that gave rise to the accusations notice are resolved which poses potential health, safety, and personal rights risks to resident in care.
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Type A
06/16/2026
Section Cited
CCR87224

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Eviction Procedures: 87224 licensee may evict a resident one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph
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Licensee will follow title 22 regulation regarding the eviction procedures provide proof of notice and assistance with relocation and any other regulatory procedures regarding the eviction process.
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Based on observation, interviews and record review, the Licensee did not comply with the section cited above by not ensuring a written notices and procedures were provided to the residents or residents responsible parties in three (3) out of three (3) residents in care which poses potential health, safety, and personal rights risks to resident 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.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2026


LIC809 (FAS) - (06/04)
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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: HILLS OF SOUTH LANE II, THE
FACILITY NUMBER: 365530259
VISIT DATE: 06/15/2026
NARRATIVE
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 During today's visit, LPA observed two (2) Caregiver providing care and supervision and verbally confirmed that:

1.) The accusation notice was not posted at the facility, and the written notice to residents and/or responsible party if any and long term care ombudsman (LTCO) were not sent as required by law since 05/08/2026.

2.) Written notice in at least 14-point type was not posted in a conspicuous location in the facility since 5/8/2026.

3.) Per Title 22 Regulation the Eviction Procedures were not followed and residents or residents responsible parties have not received an eviction notice or assistance with relocation 05/08/2026.

Caregiver was informed that a deficiency will be issued today.

An exit interview was conducted where this report, LIC809, LIC809C, LIC809D and Appeal Rights were discussed, and copies were provided to Caregiver Marc Zalameda.

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2026
LIC809 (FAS) - (06/04)
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