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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880876
Report Date: 11/15/2021
Date Signed: 11/16/2021 08:27:19 AM

Document Has Been Signed on 11/16/2021 08:27 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SUNSONG HOMEFACILITY NUMBER:
361880876
ADMINISTRATOR:CORONADO, VALERIEFACILITY TYPE:
735
ADDRESS:1045 SUNSONG COURTTELEPHONE:
(909) 988-9583
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY: 4CENSUS: 3DATE:
11/15/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:19 AM
MET WITH:Valerie CoronadoTIME COMPLETED:
12:55 PM
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LPA"s Rohit Lama, Bernadette Allen and Javier Prieto made an unannounced visit to the facility there were two employees (Staff 1) and (Staff 2) and Administrator Valerie Coronado. The visit was conducted because of death report received 11/12/2021. The death occurred on 11/4/2021 while (Staff 3) was working. LPA's were there to receive documents for R1 Passing which administrator Valerie has agreed to scan and email forms to community care License.

The following information was requested from file
Clients Information page
ID and emergency information
Admissions agreement
Placement checklist
Current IPP
Client/progress notes,
Additional note from Staff 1
Primary care and physician notes
Current medication list
P&I Ledger

In addition to gathering the necessary documents, LPA's also discussed the events of the incident with the administrator to better understand the timeline of the reported death. Valerie was at the hospital at the time of death and a coroner's report number provided.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2021
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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