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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880747
Report Date: 05/09/2024
Date Signed: 05/09/2024 04:04:27 PM

Document Has Been Signed on 05/09/2024 04:04 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CHIHUAHUA HOMEFACILITY NUMBER:
331880747
ADMINISTRATOR/
DIRECTOR:		SHAYLA RODRIGUEZFACILITY TYPE:
735
ADDRESS:77595 CALLE CHIHUAHUATELEPHONE:
(442) 256-4174
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY: 4CENSUS: 3DATE:
05/09/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Jasmine Toledo, Direct Support ProfessionalTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Javina George made an unannounced case management visit to the facility to follow up on Client #1 (C1's) death and to conduct a health and safety check. LPA met with Direct Support Professional (DSP) Jasmine Toledo and explained the purpose of today's visit. LPA spoke with Administrator John Eddington via telephone. At the time of the visit there was (2) staff and (2) client's present.

During LPA's visit, LPA reviewed and obtained copies of pertinent documentation and conducted staff interviews regarding the death of C1 who passed away on 05/07/24. LPA interviewed for further information regarding the death of C1 and the events that led up to C1's death.

The preliminary cause of death is suspected as cardiac arrest. LPA advised to send a copy of the death certificate to the department as soon as it is becomes available.

No deficiencies were cited during this visit, as there were no health and safety concerns observed during today's visit.

An exit interview was conducted and a copy of this report (LIC 809) and LIC 811 (confidential names list, were provided to Jasmine Toledo, DSP.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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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