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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880948
Report Date: 02/22/2023
Date Signed: 02/22/2023 02:04:06 PM

Document Has Been Signed on 02/22/2023 02:04 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:VNL ARF II LLCFACILITY NUMBER:
361880948
ADMINISTRATOR:ANN CLARKFACILITY TYPE:
735
ADDRESS:1205 W. BOHNERT AVETELEPHONE:
(909) 990-0299
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY: 3CENSUS: DATE:
02/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Ann Clarke, AdministratorTIME COMPLETED:
02:03 PM
NARRATIVE
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Licensing Program Analysts, Amber Coleman, (LPA Coleman) and Amy Goldenberg, (LPA Goldenberg) arrived at the VNL ARF II to conduct a Case Management Visit for Health and Safety in response to an Adult Death. LPA's introduced self and stated purpose of the visit. Administrator, Ann Clarke answered the door and granted LPA's entry. LPAs introduced themselves and stated the purpose of the visit.

During the visit, LPAs reviewed the records and collected:
-Progress Notes
-Medication Administrative Records
-LIC602 -Physician's Report
-Central
-IPP (Individual Program Plan)
-Dr. Visit Records
-Conservator contact information
-Special Incident Reports
-Reports from the Inland Regional Center


LPA Coleman and Administrator discussed the timeline of events which lead to the resident's decline in health and admission to the hospital. The resident was assigned a Conservator, who was present during the resident's stay in the hospital. Administrator stated that if a Death Certificate was produced, it was provided to the Conservator.

Due to the high volume of records collected, LPA's collected the requested documents, took them to the Community Care Licensing Office to make copies. Administrator and LPA's then coordinated a second visit to return the resident's documents to the facility. A total of 192 pages of 8.5in. x 11in. documents were removed from the resident's records. LPA's left the visit at 2:00pm and will return the records by 5pm today (2/22/23)

LPA's observed no deficiencies. A copy of this report was discussed then provided to the Administrator, Ann Clarke.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2023
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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