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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408885
Report Date: 02/15/2022
Date Signed: 02/15/2022 01:30:51 PM

Document Has Been Signed on 02/15/2022 01:30 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 INC-NATALIEFACILITY NUMBER:
336408885
ADMINISTRATOR:ERICA MAY NUEVAFACILITY TYPE:
735
ADDRESS:1850 NATALIE LANETELEPHONE:
(951) 780-0947
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY: 6CENSUS: 6DATE:
02/15/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jamielah Fortajada, StaffTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to investigate concerns relating to alleged staff abuse. The LPA met with staff, Jamielah Fortajada, and informed her of the purpose of the visit.

The Department received a Special Incident Report (SIR) from the facility on February 04, 2022. The report indicated Chief Executive Officer (CEO), Michael Hall, was notified on January 31, 2022, by Client One (C1) of concerns relating to Staff One (S1) returning to the facility as an employee. The report states C1 voiced concerns of S1 previously threatening to increase the client's medication, physically abusing C1 and other clients and taking food away from another client. No further details were provided.

On this visit the LPA conducted staff/resident interviews, reviewed records and took copies of pertinent documentation. No citations have been issued at this time. The LPA will continue the investigation and follow up if health and safety violations are observed to have taken place.

This report was reviewed with Fortajada and a copy was provided.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2022
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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