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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800445
Report Date: 02/13/2023
Date Signed: 02/13/2023 11:03:43 AM

Document Has Been Signed on 02/13/2023 11:03 AM - 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:FAITH QUALITY CARE FACILITYFACILITY NUMBER:
361800445
ADMINISTRATOR:ROMEL C CAPALARANFACILITY TYPE:
735
ADDRESS:1614 WILSON AVENUETELEPHONE:
(909) 697-9843
CITY:UPLANDSTATE: CAZIP CODE:
91784
CAPACITY: 6CENSUS: 2DATE:
02/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Joan Cole, CaregiverTIME COMPLETED:
11:15 AM
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Licensing Program Analyst, Amber Coleman (LPA) arrived unannounced to the Faith Quality Care Facility to conduct a Case Management Visit in response to an an Adult Death. LPA introduced self and stated purpose of the visit. LPA was greeted by Caregiver, Joan Cole (S1) who also invited LPA inside facility.
S1 reported that there were current no residents present at the time. S1 contacted the Administrator who arrived later during visit.

During visit, LPA walked through the facility, interviewed staff members regarding detailed of the R1's death, and collected copies of documents pertinent to Resident #1.LPA also requested additional documentation be sent to the Department, such as, the Death Certificate, upon availability.

No deficiencies were cited during visit. An exit interview was conducted where this report was discussed, and a copy was provided to Administrator at the conclusion of the visit.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2023
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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