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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412341
Report Date: 08/24/2021
Date Signed: 08/24/2021 11:32:43 AM

Document Has Been Signed on 08/24/2021 11:32 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:MAYBERRY HOUSE, THEFACILITY NUMBER:
336412341
ADMINISTRATOR:DEBORAH STANGELFACILITY TYPE:
735
ADDRESS:40678 MAYBERRY AVETELEPHONE:
(951) 652-3556
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY: 4CENSUS: DATE:
08/24/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Veda Hervey, AdministratorTIME COMPLETED:
11:40 PM
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced case management visit to the facility. LPA Gardner met with Administrator Veda Hervey and explained the purpose of today's visit.

This case management visit consisted of collecting pertinent documentation and conducting a staff interview regarding the death of Resident #1 (R1). LPA Gardner interviewed Administrator Veda Hervey for information leading up to the death of R1. R1 frequently leaves the facility and has done so on an average of twice per month for the past 3 months, as well as 2 times from the hospital in an average duration of 1.5 weeks. It should be noted that R1 was ambulatory and was not conserved.


When a resident leaves the facility, the facility attempts to keep the resident by verbal redirection, and if unsuccessful, will notify the Riverside County Sheriff's Department.

At the time of this report, an official death report from the Riverside County Coroner's Office was not complete to provide the cause of death.

No deficiencies were cited during this visit. An exit interview was conducted and a copy of this report was provided to General Manager Shanay Waters.
SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2021
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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