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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412357
Report Date: 01/09/2024
Date Signed: 01/09/2024 01:09:03 PM

Document Has Been Signed on 01/09/2024 01:09 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SLB INC-HONORS WAYFACILITY NUMBER:
336412357
ADMINISTRATOR:JEFFREY CASTILLOFACILITY TYPE:
735
ADDRESS:26938 HONORS WAYTELEPHONE:
(951) 776-0424
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 6CENSUS: 5DATE:
01/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:Jeffrey Castillo - AdministratorTIME COMPLETED:
01:17 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced Case Management Incident visit. LPA was greeted and granted entry by Staff Noemi Guerrero who was informed of the purpose of the visit. Chief Executive Officer (CEO) Michael Hall and Administrator Jeffrey Castillo arrived shortly after to greet LPA. The visit is in response to the death of Client One (C1), whom passed away on 01/06/2024.

LPA conducted a tour of the facility, interviews, and collected documents. LPA reviewed C1's file and obtained copies of the following: ID/emergency Information, admission agreement, Physician's reports, Functional Capabilities Assessment, Individual Program Plan, progress notes, and medication records (MARs) for the last 30 days. LPA also requested a copy of C1s death certificate when it is made available.

During today's visit no deficiencies were cited in regard to this incident.

An exit interview was conducted, and a copy of this report was provided to Administrator Jeffrey Castillo along with a copy of the LIC 811.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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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