336424483-10-28-2021-18-AS-DCUS-C88UCE-20211028152748

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336424483
Report Date: 10/28/2021
Date Signed: 10/28/2021 03:27:58 PM

Document Has Been Signed on 10/28/2021 03:27 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:	A BETTER WAY OF LIFE		FACILITY NUMBER:	336424483
ADMINISTRATOR:	SONIA CAZAS-GREER		FACILITY TYPE:	735
ADDRESS:	4834 GREGORY ROAD		TELEPHONE:	(951) 236-7424
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92501
CAPACITY: 6		CENSUS: 5	DATE:	10/28/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	License/ Administrator, Richard Cazas		TIME COMPLETED:	03:40 PM

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Licensing Program Analyst (LPA) David Cuevas conducted an unannounced Case Management visit to facility regarding a death report received at regional office on 10/25/2021. LPA met with staff. Sabrina Administrator/Licensee, Richard Cazas was called and arrived at the facility shortly after.

During case management visit LPA interviewed Administrator, and reviewed residents #1 (R1)’s file.

Per interview and available records resident passed away on 10/22/2021 approximately 4:30 PM. Per staff interview, resident # 1 (R1) was using facility bathroom when staff noticed that R1 had been in there longer than usual. That is when staff proceeded to check on R1 and found R1 unresponsive, staff immediately called 911 paramedics. Staff proceeded to move R1 right outside bathroom and began CPR until the paramedics arrived approximately 4:11 PM and took over CPR; However, paramedics were unsuccessful in resuscitating R1 and pronounced decease at approximately 4:30 PM at the facility. During visit LPA requested and obtain the following documents:

1. Admission Agreement

2. Needs and Service Plan

3. Psychiatric Evaluation and Medical Notes/Orders

4. Unusual Incident Reports

5. Resident Daily Notes

6. ID/ Emergency Information

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: A BETTER WAY OF LIFE	FACILITY NUMBER: 336424483
	VISIT DATE: 10/28/2021

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8. Physicians Report

9. Medication Administration Records (MAR)

10. Personal Property Record

11. Weight Record

12. Laboratory Paperwork.

A death report has not been submitted yet; however, per Administrator a death report will be submitted by tomorrow 10/29/21. Additionally, per administrator, a police report and death certificate will be requested this week and provided to CCL, when available.

No deficiencies observed during today’s visit.

An exit interview was conducted, were this report was reviewed and provided to facility, Administrator Richard Cazas.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

LIC809 (FAS) - (06/04)

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