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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336411357
Report Date: 01/11/2022
Date Signed: 01/12/2022 07:37:28 AM

Document Has Been Signed on 01/12/2022 07:37 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:SLB INC CALLE PRIMAFACILITY NUMBER:
336411357
ADMINISTRATOR:COTADELA BALATBATFACILITY TYPE:
735
ADDRESS:21650 CALLE PRIMATELEPHONE:
(951) 776-0424
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 6CENSUS: 5DATE:
01/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Cotadela Balatbat, AdministratorTIME COMPLETED:
11:22 AM
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to conduct a case management visit to address an incident involving the death of Client One (C1).

The Department received a voice message on the Duty Line from the facility on 01/07/2022 regarding the client's death on 01/07/2022. A subsequent death report was received on 01/11/2022. A Special Incident Report (SIR) details the client, on 01/07/2022, was observed to have labored breathing while they were sitting in the dinning area after breakfast time. The report details facility staff contacted emergency medical services (911) after observing the client not to be breathing normally. A review of records revealed C1 had a prior hospitalization for a Urinary Tract Infection (UTI), for which medication was prescribed and the prescription completed. A follow up medical appointment was scheduled for 010/9/22. Staff interviews corroborated the summary of events reported in the SIR and Death reports.

No information was received by the LPA to indicate there was any lack of care and/or supervision. No citations have been issued at this time. This report was reviewed with Balatbat and a copy provided.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2022
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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