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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880644
Report Date: 02/24/2022
Date Signed: 02/24/2022 11:36:20 AM

Document Has Been Signed on 02/24/2022 11:36 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CRENSHAW TOWN AND COUNTRY GUEST HOME 1 LLCFACILITY NUMBER:
331880644
ADMINISTRATOR:REAVES, ARTAGOFACILITY TYPE:
735
ADDRESS:2346 FIREBRAND AVETELEPHONE:
(909) 475-9075
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY: 4CENSUS: 2DATE:
02/24/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee, Artago Reaves TIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA), David Cuevas conducted an unannounced Case Management visit to facility regarding an adult death report to regional office on 02/22/2022. LPA met with Administrator/Licensee, Artego Reaves who was informed the purpose of visit.

During case management visit LPA interviewed staff and reviewed residents #1 (R1)’s file.

Per interview and available records resident passed away on 02/22/2022 approximately 4:00 am at Loma Linda Medical Center. Per staff interview, resident # 1 (R1) was first taken to hospital on 2/16/22 due to staff noticing R1 to be lethargic. On 2/17/22 while at the hospital R1 was treated for low thyroid level and was pending right hip drainage for fluid. However, while at hospital unrelated health concerns developed when R1 choked on a piece of food that made its way to the lungs. On 2/20/22 R1 was moved from the emergency room (ER) to a hospital room. R1’s family was informed of new health development and given options for treatment. On 2/22/22 approximately 12:00 am, Licensee received a call from R1’s family communicating that R1 was not doing well, later that morning at 4:00 AM Licensee received a call from Hospital Doctor, who proceeded to inform Licensee of R1’s passing. On 2/22/22 approximately 9:00 AM Licensee proceeded to inform Inland Regional Center (IRC) and Community Care Licensing (CCL) of R1’s death. During today’s visit LPA requested and obtain the following documents:

· Admission Agreement

· Needs and Service Plan

· Psychiatric Evaluation and Medical Notes/Orders

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CRENSHAW TOWN AND COUNTRY GUEST HOME 1 LLC
FACILITY NUMBER: 331880644
VISIT DATE: 02/24/2022
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· Unusual Incident Reports

· Resident Daily Notes

· ID/ Emergency Information

· Physicians Report

· Medication Administration Records (MAR)

· Personal Property Record

· Weight Record

· Laboratory Paperwork.

A death report has not been submitted yet; however, per Licensee death report will be submitted by 02/24/22 5:00 PM. No coroners report available yet, per Licensee when he obtains a copy it will be provided to CCL..

No deficiencies observed during today’s visit.

An exit interview was conducted were this report was reviewed and provided to facility, Licensee Artego Reaves.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022
LIC809 (FAS) - (06/04)
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