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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800226
Report Date: 08/24/2021
Date Signed: 08/24/2021 04:43:56 PM

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:LA FUENTE LAVENDER IIFACILITY NUMBER:
361800226
ADMINISTRATOR:REBEKAH LEGASPIFACILITY TYPE:
740
ADDRESS:16510 GALA AVETELEPHONE:
(909) 320-8805
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY:6CENSUS: DATE:
08/24/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Chandler RamasTIME COMPLETED:
04:45 PM
NARRATIVE
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LPA Prieto conducted this case management office visit to record deficiencies found during a complaint investigation for complaint control number: 18-AS-20190717134234 dated 7/17/2019.

The investigation revealed that resident 1 (R1) moved into the facility in April 2019. On 6/6/2019, R1 finished eating lunch and walked outside on the back patio. Staff observed R1 but did not check on R1 for approximately 30 minutes. When the staff went to check on R1 they notice R1 was not there. R1 had left the facility through the back gate. R1 was located one residential block from the facility on the ground surrounded by onlookers who called 911 and R1 transported to Arrowhead Regional Trauma Center. The facility staff contacted R1’s responsible party to inform that R1 had walked out of the facility, down the street, fell and sustained injuries. Interviews revealed that on 6/6/2019, there were two facility staff present at the facility. R1 returned to the facility on 6/12/2019, receiving Hospice services and on June 16, 2019, R1 passed away. R1 was not able to be out in the community unsupervised due to diagnoses. Refer to LIC809D for deficiencies cited. An exit interview was conducted and this report, LIC809D, and appeal rights were discussed and provided to Chandler Ramas.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
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: LA FUENTE LAVENDER II
FACILITY NUMBER: 361800226
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/20/2021
Section Cited

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87468.2(a)(4) Personal Rights:
In addition to the rights listed in Section 87468.1, (4) To care, supervision, and services that meet their individual needs sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: The Licensee did not ensure resident was
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protected from wandering from the facility. Based on interviews, observations, and record review, facility failed to provide supervision resulting in R1 wandering from the facility and sustaining injuries. This poses an immediate health and safety threat to residents in care.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2021
LIC809 (FAS) - (06/04)
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