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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880499
Report Date: 03/02/2022
Date Signed: 03/02/2022 01:06:30 PM

Document Has Been Signed on 03/02/2022 01:06 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BRACOST IVFACILITY NUMBER:
361880499
ADMINISTRATOR:RAFAEL ALPIZARFACILITY TYPE:
735
ADDRESS:1989 MESA DRIVETELEPHONE:
(909) 376-3517
CITY:COLTONSTATE: CAZIP CODE:
92324
CAPACITY: 6CENSUS: 5DATE:
03/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:51 AM
MET WITH:Rafael AlpizarTIME COMPLETED:
01:08 PM
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Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit to the facility. The LPA arrived at the facility in order to conduct a case management visit to follow up on a client death. LPA met with DSP Elizabeth Alarcon and explained the purpose of today's visit. Administrator Rafael Alpizar arrived at the facility shortly.

This case management visit consisted of collecting pertinent documentation and conducting staff interviews in regards to the death of Client #1 (C1). LPA interviewed Staff #1 (S1) and Staff #2 (S2) for further information in regards to the death of C1 and the events that led up to C1's death. S1 stated that no official death certificate has been issued at this time but the preliminary cause of death is believed to be natural, as relayed by C1's sister, who was contacted by the local medical center where C1 was taken by emergency services on 2/27/2022. LPA has advised the Administrator to send a copy of the death certificate the Community Care Licensing Division (CCLD) Riverside Regional Office as soon as 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 the Administrator Alpizar.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2022
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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