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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423920
Report Date: 09/17/2021
Date Signed: 09/17/2021 01:06:57 PM

Document Has Been Signed on 09/17/2021 01:06 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-SIERRA BRAVOFACILITY NUMBER:
336423920
ADMINISTRATOR:BELUSO, LYDAFACILITY TYPE:
735
ADDRESS:25602 SIERRA BRAVO CT.TELEPHONE:
(951) 247-7585
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92551
CAPACITY: 6CENSUS: 5DATE:
09/17/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:42 AM
MET WITH:Jeffrey Castillo, AdministratorTIME COMPLETED:
01:10 PM
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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 an Unusual Incident Report (UIR) from the facility on 09/16/2021 regarding the emergency incident proceeding the client's death on 09/15/2021. A subsequent death report was received on 09/17/2021. The UIR details the client, on 09/15/2021, was found unconscious by Staff One (S1) in their bedroom. The report details the client, prior to death, was administered additional medication to address a health condition, for which their Primary Care Physician (PCP) provided the orders. Based on records review and interviews, the client's condition returned to normal at approximately 3:30 PM. The client requested to be transferred to their bedroom, where they were later check on at 5:39 PM. Interviews reported Staff Two (S2) contacted emergency medical personnel, who arrived approximately five minutes later. C1 was pronounced dead by paramedics at 6:10 PM.

No information was received by the LPA to indicate any lack of care and/or supervision at this time. No citations have been issued at this time.

This report was reviewed with Castillo and a copy provided.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2021
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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