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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880686
Report Date: 10/28/2022
Date Signed: 10/28/2022 03:45:25 PM

Document Has Been Signed on 10/28/2022 03:45 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
, CA 92507
FACILITY NAME:HELPING HEARTS BLACKWOODFACILITY NUMBER:
361880686
ADMINISTRATOR:CESAR ARGUETAFACILITY TYPE:
772
ADDRESS:11253 BLACKWOOD STTELEPHONE:
(909) 677-6644
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY: 6CENSUS: 6DATE:
10/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:21 PM
MET WITH:Daniel GomezTIME COMPLETED:
03:50 PM
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Licensing Program Analysts (LPAs) Anna Bueno and Amber Coleman conducted an unannounced visit to the facility to conduct a case management visit regarding an incident report regarding medication error. LPAs met with staff Felipe Ybarra. Program Manager Daniel Gomez arrived during the inspection tour and Supervising Program Director Blythe McClanahan arrived shortly.

The reported incident is regarding Client 1 (C1) who missed a 5 PM medication on 10/20/2022. At approximately 7 PM, the facility discovered the error and contacted the nurse advise line who instructed the facility not to administer the medication for this day.

The facility completed a recent training for medication administration and identifying medication errors that was discussed with Ms. McClanahan and Mr. Gomez. An exit interview was conducted where this report was discussed and provided to Mr. Gomez
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2022
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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