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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423933
Report Date: 08/29/2023
Date Signed: 08/29/2023 04:43:22 PM

Document Has Been Signed on 08/29/2023 04:43 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-ZITEOFACILITY NUMBER:
336423933
ADMINISTRATOR:ERICA MAY NUEVAFACILITY TYPE:
735
ADDRESS:23278 ZITEO CT.TELEPHONE:
(951) 776-0424
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 6CENSUS: 5DATE:
08/29/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Michael Hall, CEOTIME COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced Case Management Incident visit. LPA was greeted and granted entry by CEO Michael Hall. LPA explained the purpose of the visit and toured the facility. The visit is in response to the death of Client #1 (C1), whom passed away on 08/29/2023.

During LPA's visit, LPA reviewed C1's file and obtained copies of the following: ID/emergency Information, admission agreement, Physician's reports, Psychiatric notes, 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 CEO Michael Hall along with a copy of the LIC811.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2023
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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