<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880495
Report Date: 03/26/2024
Date Signed: 03/26/2024 02:10:48 PM

Document Has Been Signed on 03/26/2024 02:10 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BRACOST IFACILITY NUMBER:
361880495
ADMINISTRATOR:EDIMAR MARQUESFACILITY TYPE:
735
ADDRESS:1096 CANTARA STREETTELEPHONE:
(909) 376-3517
CITY:COLTONSTATE: CAZIP CODE:
92324
CAPACITY: 6CENSUS: 2DATE:
03/26/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:San Juana Najera - DSPTIME COMPLETED:
02:11 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Anna Fannell conducted an unannounced case management visit to the facility to follow up on a client death. LPA met with direct support provider (DSP) San Juana Najera who was informed of the purpose of today's visit. DSP notified Licensee Marques of LPA's presence at the facility.

On the evening of 03/22/2024, LPA received a voicemail message from administrator Edimar Marques regarding the hospitalization and subsequent passing of Client (C1). On 03/25/2024, the San Bernardino Regional Office received a death report of C1. The death report stated C'1s cause of death, as relayed by the medical practitioner from the local medical center where C1 was taken by emergency services on 03/22/2023.
Today's visit consisted of collecting pertinent documentation and interviewing staff regarding events that led up to C1's hospitalization. LPA requested facility staff to send a copy of the death certificate to the Regional Office when it is available. No deficiencies were cited during this visit. An exit interview was conducted where this report (LIC 809) and LIC 811 were discussed and provided to Ms. Najera
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Fannell
LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1