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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880964
Report Date: 04/02/2024
Date Signed: 04/02/2024 04:30:24 PM


Document Has Been Signed on 04/02/2024 04:30 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:CADENCE AT RANCHO CUCAMONGAFACILITY NUMBER:
361880964
ADMINISTRATOR:CYNTHIA FIGUEROAFACILITY TYPE:
740
ADDRESS:10459 CHURCH STREETTELEPHONE:
(909) 918-5546
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY:117CENSUS: 94DATE:
04/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Gen Diaz, Business Office Director TIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a case management visit regarding an incident that occurred with resident #1 (R1) at the facility. LPA Prieto met with Business Office Director Diaz and explained the element of the visit. LPA Prieto interviewed R1, who stated that the memory of the incident was not certain, but once repeated to from the written incident report the incident of walking out to the facility courtyard sounded familiar and something the R1 would do to get fresh air. Facility staff followed the proper protocol of notifying medical response team, responsible parties and Licensing staff. LPA Prieto obtained pertinent documentation related to this incident. No deficiencies were cited during this visit. This report was signed by LPA Prieto and MS Diaz and a copy was left at the facility.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
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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