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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881034
Report Date: 01/09/2023
Date Signed: 01/09/2023 01:53:46 PM


Document Has Been Signed on 01/09/2023 01:53 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:BROOKDALE LOMA LINDAFACILITY NUMBER:
361881034
ADMINISTRATOR:LUJAN, MARITZAFACILITY TYPE:
740
ADDRESS:25585 VAN LEUVEN STREETTELEPHONE:
(909) 796-5421
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:220CENSUS: 109DATE:
01/09/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Maritza Lujan Administrator TIME COMPLETED:
02:00 PM
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 Licensing Program Analysts (LPA) Bernadette Allen conducted an unannounced visit to the facility to conduct a case management visit and follow up on an adult client death. LPA Allen met with Maritza Lujan administrator who was informed of the purpose of the visit.

This case management visit consisted of collecting pertinent documentation and conducting staff interviews in regard to the death of Client #1 (C1). LPA Allen interviewed Staff #1 (S1) and Staff #2 (S2) for further information in regard to the death of (C1) and the events that led up to (C1's) death.

(S1) stated that there is no official death certificate or cause of death at this time. LPA Allen has advised the administrator to send a copy of the death certificate to Community Care Licensing Division (CCLD) Riverside Regional Office as soon as it is available.

An exit interview was conducted where this report was discussed with Maritza Lujan and a copy was provided at the conclusion of the visit.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2023
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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