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Health Inspection

Shandin Hills Behavior Therapy Center

February 20, 2026 · San Bernardino, CA · 4164 N 4th Ave
Citations 4
CMS Rating 5/5
Beds 78
Provider ID 05A208
Healthcare Facility
Shandin Hills Behavior Therapy Center
San Bernardino, CA  ·  View full profile →
Inspection Summary

Shandin Hills Behavior Therapy Center in San Bernardino, CA — inspection on February 20, 2026.

Found 4 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0689
Quality of Life and Care Deficiencies

During an observation on February 18, 2026, at 7:27 AM, surveyor found multiple keys that opened locked behavior doors and units hanging on the outside of the main entrance gate.

There were no staff at the gate.

Once the surveyors entered the building through the main entrance door, they proceeded through a second door, which leads directly to the resident's dining room.During a concurrent observation and interview on February 18, 2026, at 7:29 AM, with Licensed Vocational Nurse (LVN) 1 inside the building, LVN 1 stated, the main entrance door should be locked at all the time. LVN 1 stated, her keys were in her pocket, however as she Searched her pocket for the keys, she did not find them. LVN 1 stated, Oh may be at the door, let me see where I left it. LVN 1 walked to the main gate to look for her keys.

Surveyor informed her she had the keys from the gate and gave them to LVN 1.During a concurrent interview and record review on February 18, 2026, at 8:28 AM, with Administrator (Admin), the facility's policy and procedure (P&P) titled, Facility Security and Locked Door, undated, was reviewed.

The P&P indicated, The policy statement the facility maintains a secure therapeutic environment.

Locked doors and controlled access measures are utilized. 6.

Access control procedures, Exterior doors remain secured.

Admin, stated, it is a safety issue, door must be always locked.

Admin stated the keys should not have been left on the gate.

Admin further stated, the keys must always be with staff and staff are not to leave keys anywhere.

Admin stated, staff reviewed and signed the competency Skills for possession of door key.

Admin acknowledged the facility P&P was not followed.

During a concurrent interview and record review on February 19, 2026, at 1:51 PM, with LVN 1 the facility's Competency skills: Staff Possession of Door Key in A locked Unit, (date [undated]) was reviewed.

The Competency Skills indicated, Staff must secure (as part of the uniform) the door/gate key used to enter and exit the facility, key to lock the unit and not leaving it anywhere.

Staff must immediately inform the supervisor if door/gate key is missing. LVN 1 stated she should not have left the keys at the gate. LVN 1 stated, she was educated and signed the competency. LVN 1 stated the risk of leaving the key at the gate, that unwanted visitors can enter the building, and the safety of the residents can be compromised.

05A208 02/20/2026

Shandin Hills Behavior Therapy Center 4164 N 4th Ave San Bernardino, CA 92407

During a concurrent observation and interview on February 17, 2026, at 8:29 AM, with

tray of the ovens located beneath the stove.

The left lower oven had heavier accumulation of dark residue and debris on the interior surfaces and bottom tray.

The lower right oven also had dark buildup and debris present on interior surfaces and racks.

The AM 1 confirmed and stated that it should be clean.During a concurrent interview and record review on February 20, 2026, at 12:29 PM, with Account Manager (AM 1), the facility policy titled Environment, revised June 2025, was reviewed.

The Policy indicted, All food preparation areas, food services and dining areas will be maintained in a clean and sanitary condition. 3.

All food contact surfaces will be cleaned and sanitized after each use. 4.

The Dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas and surfaces.

The AM 1 confirmed that the policy was not followed.

During a concurrent observation and interview on February 17, 2026, at 8:46 AM, with the AM 1, in the emergency food storage room, the area was observed unclean.

Visible dust accumulation was noted on the floor surfaces and shelving units.

There was dust on multiple large blue water containers stored on the shelving. A total of nine large blue water containers were stored in the room.

Additionally dry leaves and debris were scattered on the floor throughout the storage area.

The surrounding floor surfaces appeared unclean with visible buildup and debris present.

The AM 1, was present during the observation, confirmed the condition of the storage room and stated the area should be kept clean to ensure proper sanitation of stored emergency food and water supplies.

During a follow up interview on February 20, 2026, at 12:18 PM, with the Admin, the Admin stated the facility did not have an established cleaning schedule for the emergency supplies room and confirmed that the last time it was cleaned was December 2025.

The Admin further stated the facility did not have cleaning log in place and reported plans to initiate a cleaning log beginning February 20, 2026.

During a concurrent interview and record review on February 20, 2026, at 12:23 PM, with Account Manager (AM 1), the facility policy titled Food Storage: Dry Goods Revised February 2023 was reviewed.

The policy indicated that all dry goods will be appropriately stored in accordance with the FDA Food Code. 5.

All packed and canned food items will be kept clean, dry and properly sealed. 6.

Store areas will be neat, arrange for easy identification, and date marked as appropriate.

The AM 1, confirmed that the policy was not followed.

During a review of the FDA Food Code 2022, 6-501.12 Cleaning Frequency and Restrictions, indicated, (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean.

05A208 02/20/2026

Shandin Hills Behavior Therapy Center 4164 N 4th Ave San Bernardino, CA 92407

During a review of the FDA (Food and Drug Administration) Food Code 2022, 5-501.15, indicated, (A) Receptacles and waste handling units for REFUSE, recyclables, and returnable used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers.

05A208 02/20/2026

Shandin Hills Behavior Therapy Center 4164 N 4th Ave San Bernardino, CA 92407

During the observation, residents occupying the rooms were observed utilizing the available space without immediate safety concerns Room configurations appeared consistent with the current facility layout.

During an interview conducted on February 18, 2026, 9:45 AM with MDIR, the MDIR confirmed the measurements obtained and stated there have been no additions or structural changes made to increase size of the resident rooms in Unit 2.

During a concurrent interview and record reviewed on February 19, 2026, at 5:21 PM, with the Administrator, (Admin) the facility policy and procedure (P&P) titled Bedrooms revised January 2025. was reviewed.

The P&P indicated, 2.

Bedrooms measure at least 80 square feet or usable living space per resident in double rooms and at least 100 square feet of usable living space in single rooms.

The Admin confirmed the policy requirements were not followed.

Measurements obtained during the survey confirmed the resident rooms did not meet the minimum square footage required by facility policy.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in San Bernardino, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Shandin Hills Behavior Therapy Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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