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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602971
Report Date: 01/16/2024
Date Signed: 01/16/2024 02:31:15 PM

Document Has Been Signed on 01/16/2024 02:31 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:YEARLING ARF INCORPORATEDFACILITY NUMBER:
198602971
ADMINISTRATOR:MACHADO, MARYFACILITY TYPE:
735
ADDRESS:11309 YEARLING STTELEPHONE:
(714) 875-8388
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 4CENSUS: 3DATE:
01/16/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:54 PM
MET WITH:Administrator Norlan MachadoTIME COMPLETED:
02:46 PM
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On 1/16/2024 at 12:54 p.m., Licensing Program Analyst (LPA) Jewel Baptiste initiated a case management visit to follow-up on the death of Client #1 (C1). Upon arrival there was no one at home. LPA contacted Administrator Mary Machado and explained the reason for the visit. At 1:30 pm, Staff#1 (S1) greeted LPA. According to S1 all clients attend a day program from 1 pm to 5 pm. The Administrator Norlan Machado arrived at 1:45 pm.

The facility completed a death report for C1 dated 12/24/24. According to the report, C1 passed away at West Anaheim Medical Center on 12/24/2023. The Administrator and S1’s interviews confirmed, C1 was sent to the hospital on 12/3/2023 due to a fever. C1 was then admitted into a nursing home and stayed there for 2 weeks. C1 was sent to West Anaheim Medical Center where they pronounced C1's death on 12/24/2023.

LPA toured the facility with S1. The tour included 4 client's bedrooms, 1 vacant bedroom, 2 bathrooms, kitchen, and common areas. LPA observed sharps, medications, and chemicals under lock. There were no health and safety concerns at the time of the visit. LPA also obtained a copy of C1’s physician’s report and IPP.

The Administrator stated C1's family member confirmed cause of death was a heart attack and will provide a copy of death certificate upon receipt.

Exit interview conducted with S1 and a copy of the report provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2024
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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