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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880686
Report Date: 06/07/2023
Date Signed: 06/07/2023 03:05:35 PM

Document Has Been Signed on 06/07/2023 03:05 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: 2DATE:
06/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Arthur Estrada - Program DirectorTIME COMPLETED:
03:06 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 Bueno conducted an unannounced case management visit to the facility due to an incident report. LPA met with BHT (behavioral health technician) Janessa Scott who phoned program director Arthur Estrada. LPA explained the purpose of today's visit BHT and program director .

On 06/05/2023, the Department was notified of the death of Client 1 (C1). During today's visit, LPA Bueno interviewed staff and witness regarding C1's death. LPA collected and reviewed records that are pertinent to C1's death, including:
    • Physician Report
    • Medication and Vitals records
    • 04/11/23 specialist visit report
    • 01/15//2021 History and Physical report
    • Daily case management notes

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the Program Director.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2023
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