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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360911547
Report Date: 01/17/2023
Date Signed: 01/17/2023 02:01:50 PM

Document Has Been Signed on 01/17/2023 02:01 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ORCHID COURT, INC.FACILITY NUMBER:
360911547
ADMINISTRATOR:GOSUICO, CLODOVEO IIIFACILITY TYPE:
735
ADDRESS:307 S. ARROWHEAD AVENUETELEPHONE:
(909) 884-3044
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92408
CAPACITY: 80CENSUS: DATE:
01/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Clodoveo Gosuico, AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst, Amber Coleman (LPA) arrived at the Orchid Court Facility to conduct a Case Management for the purposes of health and safety following an adult death. LPA introduced self and stated purpose of the visit. LPA was granted entry by staff and introduced to the Administrator Clodoveo Gosuico also known as "George". LPA was asked to sign in and have temperature taken. LPA was provided a space to work and interview the Administrator.

During the visit, LPA interviewed Administrator regarding the resident, their behavior, history with facility, events leading to incident and collected pertinent documentation regarding the death resident (R1). Administrator explained that in response to the incident the San Bernardino County Sheriff's Office made and visit along with the County Coroner. At this time, no official death certificate or cause of death has been provided. Administrator agreed to provide Community Care Licensing with these documents as soon as they are released. The resident was conserved and was assigned a representative payee.

An exit interview was conducted where this report was discussed and provided to the Administrator.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2023
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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