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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603610
Report Date: 03/08/2024
Date Signed: 03/08/2024 11:26:12 AM

Document Has Been Signed on 03/08/2024 11:26 AM - 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:RISING HILL DEVELOPMENTAL HOME IIIFACILITY NUMBER:
198603610
ADMINISTRATOR:OGLESBY, JENNIFER L.FACILITY TYPE:
735
ADDRESS:21303 E CLOVERTON STTELEPHONE:
(562) 508-2007
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 4CENSUS: 3DATE:
03/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Janeth DOrantes, administratorTIME COMPLETED:
11:45 AM
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Licensing Program Analysts (LPAs) Tao and Reyes conducted an unannounced initial case management visit regarding the death of client #1 (C1) which occurred on 02/28/24. LPA met with Administrator, Janeth Dorantes and explained the reason of the visit.

According to the incident report dated 02/29/24, C1 deceased on 02/28/24 who was found in the city of Montclair by police. The suspected cause of death was drug (Meth) overdosed.

During today's visit, administrator was interviewed, C1's file was reviewed and obtained the following:
· Staff roster and Client roster
· Client #1 (C1) facesheet dated 04/25/23
· Unusual incident report, dated 02/29/24
· Death report, dated 03/05/24
· C1's IPP, dated 5/23/23
· C1's record of Medical visit dated 5/11/23
· C1's facility notes dated Jan 2024
· C1's Admission agreement, date 4/25/23
· C1's Police's Report #024-008560871400 / C1's Coroner case # 702401726

Requested the following documents:
· C1's physician's Report. Due 3/11/24

Administrator stated she may get the death certificate and coroner report from C1's family when available. Exit interview was conducted and a copy of LIC 809 Report was provided to administrator.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2024
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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