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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800445
Report Date: 02/17/2023
Date Signed: 02/17/2023 10:32:32 AM

Document Has Been Signed on 02/17/2023 10:32 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: 1DATE:
02/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Marife ReyesTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Paola Guerrero made an unannounced visit to the facility. LPA arrived at the facility to conduct a case management visit to follow up on a client death. LPA met with Caregiver Marife Reyes and explained the purpose of today's visit.

This case management visit consisted of collecting pertinent documentation and conducting staff interviews regarding the death of Client #1 (C1) who passed away on 2/8/2023. LPA interviewed Staff #1 (S1) for further information regarding the death of C1 and the events that led up to C1's death. Staff#1 (S1) stated that no official death certificate has been issued at this time, but the preliminary cause of death was due to pneumonia related to COVID-19. LPA has advised the Caregiver to send a copy of the death certificate to the Community Care Licensing Division (Department) Riverside Regional Office as soon as it is available.

LPA spoke to C1’s mother on the telephone during today’s visit, LPA was provided the cause of death based on what they were told by the hospital.


No deficiencies were cited during this visit. An exit interview was conducted where this report (LIC 809) were discussed and provided to Marife Reyes
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2023
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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