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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408352
Report Date: 08/17/2021
Date Signed: 08/17/2021 09:07:06 AM

Document Has Been Signed on 08/17/2021 09:07 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:LUCENA ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
336408352
ADMINISTRATOR:NENITA LUCENAFACILITY TYPE:
735
ADDRESS:24782 HEIL DRIVETELEPHONE:
(951) 208-4416
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 6CENSUS: 2DATE:
08/17/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
07:50 AM
MET WITH:Vanessa Lucena, AdministratorTIME COMPLETED:
09:00 AM
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to commence a case management investigation. The LPA identified herself and discussed the purpose of the visit with Administrator, Vanessa Lucena.

The Department received a verbal notification on August 16, 2021, from the facility Administrator reporting the death of a client in care, Client One (C1). It was reported C1 chocked on a piece of food and emergency medical personnel (911) were contacted to aid. No additional details were provided.

On this visit the LPA conducted resident/staff interviews, reviewed records, and took copies of pertinent documentation. Lucena indicated the incident was reported on August 14, 2021. She reported Staff One (S1) was present at the time and was providing direct supervision to C1 when the incident occurred. She reported C1 does have a history of chocking, though the eating challenge does not take place on a normal basis. LPA observed S1 did have proof of CPR training, dated February 19, 2021, on file. The LPA will review reports received from the facility and follow-up, if necessary. No citations have been issued at this time.

An exit interview was conducted with Lucena and a copy of this report was provided.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2021
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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