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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336411389
Report Date: 03/30/2023
Date Signed: 03/30/2023 06:28:04 PM

Document Has Been Signed on 03/30/2023 06:28 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:CASA MICHANAFACILITY NUMBER:
336411389
ADMINISTRATOR:NANCY MOQUETEFACILITY TYPE:
735
ADDRESS:29161 BRIDALVEIL LANETELEPHONE:
(951) 746-3416
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY: 5CENSUS: 2DATE:
03/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Victor Manzo, Caregiver TIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Javina George made an unannounced case management visit to the facility. The purpose of the visit was to follow up on a client #1 (C1's) death. LPA met with Victor Manzo, Caregiver and Administrator Marcela Hurtado via telephone and explained the purpose of today's visit.

During LPA's visit, LPA reviewed and obtained copies of pertinent documentation and conducted staff interviews regarding the death of Client #1 (C1) who passed away on March 29, 2023. LPA interviewed Staff #1 (S1) for further information regarding the death of C1 and the events that led up to C1's death, as well as the administrator. Per the administrator Marcela, the official death certificate has been not been issued at this time, and that they are waiting to hear from the next of kin regarding the cause of death and service details.

There was no preliminary cause of death was determined or provided. LPA advised Administrator to send a copy of the death certificate to the department as soon as it is available.


No deficiencies were cited during this visit.

An exit interview was conducted and a copy of this report (LIC 809) and LIC 811 (confidential names list, were provided to Victor Manzo.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
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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