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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200735
Report Date: 11/08/2023
Date Signed: 11/08/2023 01:13:19 PM

Document Has Been Signed on 11/08/2023 01:13 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:CALIFORNIA MENTOR - MALABAR HOMEFACILITY NUMBER:
019200735
ADMINISTRATOR:JOSEPH FARRISH IIIFACILITY TYPE:
740
ADDRESS:4639 MALABAR AVETELEPHONE:
(909) 483-2505
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY: 4CENSUS: 3DATE:
11/08/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Abigail Cruz, Program SupervisorTIME COMPLETED:
12:00 PM
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On 11/8/2023 Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced case management visit regarding upon missing death report regrading a client that pass away at Eden hospital. The special incident report that submitted to CCLD on 11/3/23. LPA spoke with Abigail Cruz program supervisor and explained the purpose of the visit.

LPA interviewed staff (S1) regarding client (C1) care prior to the incident. LPA obtained death report, progress notes/ care notes, and the after-visit summary C1 was admitted to the hospital. After reviewing the documents C1 was places on hospice care on 11/1/23. C1 was seeing by C1 internal medicine doctor on 10/12/23 to access C1 medical condition. S1 stated that according to the doctor C1 was doing fine. After reviewing documents C1 cause of death is aspiration pneumonia, sepsis, and acute hypoxic respiratory failure.

No deficiencies cited. Exit Interview conducted and a copy of this report provided via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2023
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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