361800226-8-24-2021-18-AS-KCLS-C6GLRB-20210902085851

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361800226
Report Date: 08/24/2021
Date Signed: 08/24/2021 04:39:24 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/17/2019 and conducted by Evaluator Javier Prieto

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20190717134234

FACILITY NAME:	LA FUENTE LAVENDER II		FACILITY NUMBER:	361800226
ADMINISTRATOR:	SERRANO, KIMBERLY		FACILITY TYPE:	740
ADDRESS:	16510 GALA AVE		TELEPHONE:	(909) 320-8503
CITY:	FONTANA	STATE: CA	ZIP CODE:	92337
CAPACITY:	6	CENSUS: 0	DATE:	08/24/2021
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Chandler Ramas		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Lack of supervision resulting in the resident's death.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javier Prieto conducted an announced office visit to deliver findings regarding an allegation that lack of supervision resulting in the resident's death. LPA Prieto met with Chandler Ramas. The investigation consisted of Interviews and medical records review and Resident 1 (R1) sustained an injury while in care of facility resulting in R1's death. Interviews reveal that R1 was observed in facility backyard patio area by staff on June 6, 2019 and not supervised for approximately 30 minutes. Staff interviews reveal staff checked on R1 in patio area at approximately 1200 hours and noticed R1 was not at facility. Interviews reveal subsequent search by staff found R1 approximately one residential block from facility on the ground surrounded by onlookers who called 911 emergency services where R1 was treated and transported to a medical facility. CT scan reveal hemorrhage contusion of brain with overlying hematoma. Facility records review revealed R1 returned to facility on June 12, 2019 where R1 had continuous care for respiratory distress, terminal agitation/restlessness and terminal pain.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20190717134234

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 08/24/2021

NARRATIVE

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Records reveal R1 passed away on June 16, 2019 at 0256 hours and cause of death was listed as Cardiopulmonary Failure and end stages of Alzheimer Disease. Based on this information, it was not clearly ascertained on the cause of R1’s passing.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time.
No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to Mr Ramas.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2020

LIC9099 (FAS) - (06/04)

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