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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360904812
Report Date: 09/15/2023
Date Signed: 09/15/2023 12:57:31 PM


Document Has Been Signed on 09/15/2023 12:57 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
, CA 92507



FACILITY NAME:PLYMOUTH VILLAGE OF REDLANDSFACILITY NUMBER:
360904812
ADMINISTRATOR:MICHAELS, JULIEFACILITY TYPE:
741
ADDRESS:900 SALEM DRIVETELEPHONE:
(909) 793-1233
CITY:REDLANDSSTATE: CAZIP CODE:
92373
CAPACITY:303CENSUS: DATE:
09/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:44 AM
MET WITH:Erika Rodriguez - Interim DirectorTIME COMPLETED:
12:59 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to conduct a case management visit and follow up on a resident death. LPA met with interim wellness director Eika Rodriguez who was informed of the purpose of the visit.

The visit consisted of collecting pertinent documentation, inspecting the outside of R1's home, and conducting staff interviews regarding the death of Resident 1 (R1). LPA Bueno interviewed Staff 1 (S1) for further information on events leading up to R1's death. S1 stated that there is no official death certificate or cause of death at this time. LPA has requested for Wellness Director to provide a copy of the death certificate to Community Care Licensing (CCL) Regional Office when it is available.

An exit interview was conducted where this report was discussed with Erika Rodriguez and a copy was provided at the conclusion of the visit.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2023
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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