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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005349
Report Date: 06/02/2023
Date Signed: 06/02/2023 02:26:55 PM


Document Has Been Signed on 06/02/2023 02:26 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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:LAS PALMASFACILITY NUMBER:
306005349
ADMINISTRATOR:MONICA CASTILLOFACILITY TYPE:
740
ADDRESS:24962 CALLE ARAGONTELEPHONE:
(949) 586-3393
CITY:LAGUNA WOODSSTATE: CAZIP CODE:
92637
CAPACITY:220CENSUS: DATE:
06/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Monica CastilloTIME COMPLETED:
02:40 PM
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This unannounced case management visit is being conducted by Licensing Program Analyst (LPA) Ruth Martinez to follow up on an incident reported to CCLD on May 24, 2023. LPA met with Monica Castillo, Administrator and explained the purpose of today’s visit. Incidents were self reported by telephone call May 24, 2023 and LIC624 on May 25, 2023 regarding R1’s incidents on May 23, 2023.

During today’s visit, LPA interviewed administrator and obtained copies of pertinent documents.

On May 23, 2023, at approximately 7:30am med tech went to R1’s room to give morning medication. R1 was not responsive, sternum rub was done and was not effective. 911 was immediately called and paramedics arrived and assessed R1. R1 was taken to the hospital for evaluation. R1 was admitted to hospital for kidney failure and was placed on hospice. This visit is being conducted for the purpose to review and collect facility records.

This report was reviewed with Administrator and a copy of the report was provided and left at the facility.

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
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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