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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530048
Report Date: 01/08/2025
Date Signed: 01/08/2025 09:46:44 AM

Document Has Been Signed on 01/08/2025 09:46 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:EMMA'S CASE ARF INC.FACILITY NUMBER:
335530048
ADMINISTRATOR/
DIRECTOR:		CHAVEZ, ALIX GARCIAFACILITY TYPE:
735
ADDRESS:20043 CASE STTELEPHONE:
(909) 316-9555
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY: 4CENSUS: 2DATE:
01/08/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Alix Garcia ChavezTIME VISIT/
INSPECTION COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Mary Rico conducted an unannounced Case Management Incident visit. LPA met with Administrator Alix Garcia Chavez and explained the reason for the visit. The visit is in response to the death of Client 1 (C1), who passed away on 1/6/2025..

During the visit, LPA reviewed C1's file and obtained copies of the following: ID/emergency Information, Admission Agreement, Physician's reports, Inland Regional IPP, Progress/daily notes, Medication logs , medical appointments, and laboratory paperwork. LPA requested a copy of C1’s death certificate when it is made available.

During today's visit, no red flags were observed, and no deficiencies were cited regarding this incident.

An exit interview was conducted, and a copy of this report was provided to Administrator Alix Garcia Chavez.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
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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