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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424317
Report Date: 05/17/2022
Date Signed: 05/17/2022 02:25:37 PM

Document Has Been Signed on 05/17/2022 02:25 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:SAMUEL HOMEFACILITY NUMBER:
336424317
ADMINISTRATOR:SANDRA HERNANDEZFACILITY TYPE:
735
ADDRESS:41367 TRUMBLE COURTTELEPHONE:
(760) 298-1235
CITY:INDIOSTATE: CAZIP CODE:
92203
CAPACITY: 6CENSUS: 5DATE:
05/17/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sandra Hernandez - Administrator TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of following up on the death of an Adult Resident (R1), who passed on 5/14/22. LPA Colvin met with Administrator Sandra Hernandez and House Manager Stephanie Olivas and informed them of the purpose of today's visit.

LPA Colvin interviewed staff about the events leading up to R1's passing, R1's medical history, and other relevant information. LPA Colvin additionally reviewed R1's file, including medication records and recent doctor's appointments. Additional information and follow up may be required.

An exit interview was conducted with Administrator Sandra Hernandez and a copy of this report was provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
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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