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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336402597
Report Date: 09/07/2022
Date Signed: 04/26/2023 03:45:04 PM

Document Has Been Signed on 04/26/2023 03:45 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SLB INCORPORATED-OLD VALLEYFACILITY NUMBER:
336402597
ADMINISTRATOR:FORTAJADA, JAMIELAHFACILITY TYPE:
735
ADDRESS:23484 OLD VALLEY DRIVETELEPHONE:
(951) 243-9746
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 6CENSUS: 6DATE:
09/07/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:May David, CaretakerTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit to follow up on information previously reported to the Department regarding an incident between Client 1 (C1) and Staff 1 (S1). LPA explained the purpose of the visit with Ms. David, and Administrator Jamielah Fortajada arrived shortly after LPA arrived. LPA had previously conducted a facility visit on 7/20/2022 in which LPA interviewed 6 residents, and 5 staff members regarding the incident.

The facility reported that the incident took place on an undetermined previous date. Reasoning given was that C1 was not complaining of pain or voicing the incident. The incident was not witnessed by anyone other than Staff 1 (S1). S1's last date worked was 7/10/22 before not showing for their shift on 7/14/22. The incident came to light on 7/13/22 when CEO Mr. Michael Hall noticed C1 not "himself". When Mr. Hall questioned C1 about it, C1 explained the situation involving S1 slapping C1 while in the restroom. As a precaution, Hall directed their staff to take C1 to Urgent Care to be examined.

During LPA's interview with C1, C1 reported that S1 had "hit" him, and immediately after, "fell out of his chair." During the interview of S1, S1 stated that S1 was having a "bad day" and that they weren't necessarily in the mood to handle R1 that day. Instead, S1 let their emotions get the best of them, and had engaged physically with C1. S1 had admitted to Mr. Hall that the incident was physical between S1 and C1 in which Mr. Hall later terminated S1 on 7/14/22, as a result of the situation.

This is an amended version of the report dated September 7, 2022.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2022
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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Document Has Been Signed on 09/07/2022 11:49 AM - It Cannot Be Edited


Created By: Jesse Gardner On 09/07/2022 at 10:36 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SLB INCORPORATED-OLD VALLEY
FACILITY NUMBER: 336402597

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/08/2022
Section Cited
CCR
80072(a)(3)

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Personal Rights: (a)Except..personal rights which include..(3)To be free from ..punishment, infliction of pain..This requirement was not met as evidenced by:
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During visit, LPA was provided a copy of the in-service training that was conducted on 7/14/22 regarding personal rights of clients, definitions of abuse, and reporting requirements. POC cleared at time of visit.
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Based on LPA's interviews with R1, and S1, along with Administrator advising CCL of the incident where S1 slapped R1, Licensee did not comply with the regulation. This poses an immediate health and safety and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Deborah Mullen
LICENSING EVALUATOR NAME:Jesse Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2022


LIC809 (FAS) - (06/04)
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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: SLB INCORPORATED-OLD VALLEY
FACILITY NUMBER: 336402597
VISIT DATE: 09/07/2022
NARRATIVE
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In conclusion, Licensee did not provide a safe environment for R1, and due to this, was given a citation per Title 22 Division 6 Chapter 1.

An exit interview was conducted with Administrator Jamielah Fortajada and a copy of this report was discussed with and provided along with copies of the LIC811, LIC809-D, and Appeal Rights.

This is an amended version of the original report dated September 7, 2022.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
LIC809 (FAS) - (06/04)
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