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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880880
Report Date: 02/27/2024
Date Signed: 02/27/2024 01:06:25 PM

Document Has Been Signed on 02/27/2024 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BIG HEARTS COLOMA, INC.FACILITY NUMBER:
361880880
ADMINISTRATOR:CHEA, PAULFACILITY TYPE:
735
ADDRESS:10686 COLOMA STTELEPHONE:
(909) 796-2722
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY: 4CENSUS: 4DATE:
02/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Paul Chea - AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to conduct a case management visit in relation to an incident report received by Community Care Licensing Division Regional office on 9/05/23. LPA met with Paul Chea, Administrator, and discussed the purpose of the visit.

The report stated that on 8/31/23, staff #1 (S1) grabbed client #1 (C1) by both arms and walked C1 to the couch in an attempt to calm client during a behavior episode. Interviews and documentation reveal, staff reported incident to the Administrator. The Administrator notified tC1's responsible party and proper agencies. S1 was placed on leave during an internal investigation and later terminated as a result of the incident.

An exit interview was conducted where this report was discussed and a copy of the report was provided to the Administrator at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2024
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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