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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366405765
Report Date: 11/02/2021
Date Signed: 11/02/2021 01:30:49 PM

Document Has Been Signed on 11/02/2021 01:30 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
RIVERSIDE, CA 92507
FACILITY NAME:CASA COLINA CENTERS FOR REHABILITATION/PADUA VILLAFACILITY NUMBER:
366405765
ADMINISTRATOR:RODNEY PEEKFACILITY TYPE:
735
ADDRESS:22200 HIGHWAY 18TELEPHONE:
(760) 247-7711
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 54CENSUS: 33DATE:
11/02/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Rodney PeekTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Stephanie Williams conducted a visit to the facility in order to initiate a case management visit. LPA identified herself and discussed the purpose of the visit with Administrator, Rodney Peek.

The Department received a death report regarding the death of Client #1 (C1) on 10/27/21. LPA interviewed the Administrator and staff in regards to the events that led to the death of C1 and history of C1's health conditions.

LPA Williams reviewed the following documents from C1's file:
  • Unusual Incident Reports
  • Physician Discharge Notes
  • Medication Administration Record (MAR)


The Administrator stated that a death certificate has not yet been made available. LPA requested that a copy of the death certificate be sent to the Department as soon as they become available.

No deficiencies cited during this visit. An exit interview was conducted where this report was discussed via telephone and a copy was sent to Peek via email.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2021
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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