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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423920
Report Date: 01/20/2022
Date Signed: 01/20/2022 12:05:28 PM

Document Has Been Signed on 01/20/2022 12:05 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:
01/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Jeffrey Castillo, AdministratorTIME COMPLETED:
12:10 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 a Death Report from the facility on 01/19/2022 regarding the death of C1 on 01/18/2022. A previously submitted Unusual Incident Report (UIR) details the client, on 01/15/2022, was observed by facility staff to be complaining about abdominal pain. The report details the client was transported to the hospital by emergency medical personnel and admitted for possible kidney stones. Per Administrator, Castillo, the client passed away at Riverside University Health System (RUHS) from Cardiac Arrest. According to a Medical Assessment, dated 12/26/2021, R1 was previously diagnosed with a history of stroke. C1 was taking heart related medications and a medication audit did not reveal any disruption in administration.

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: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2022
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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