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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408342
Report Date: 03/28/2024
Date Signed: 03/28/2024 01:27:59 PM

Document Has Been Signed on 03/28/2024 01:27 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:MANZANITA HOMEFACILITY NUMBER:
366408342
ADMINISTRATOR:TOLENTINO, JUDYFACILITY TYPE:
735
ADDRESS:720 MANZANITA COURTTELEPHONE:
(909) 391-9300
CITY:ONTARIOSTATE: CAZIP CODE:
91761
CAPACITY: 6CENSUS: 3DATE:
03/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:09 PM
MET WITH:Ana BellTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Mary Rico conducted an unannounced Case Management Incident visit. LPA met with Care Giver Ana Bell and explained the reason for the visit. The visit is in response to the death of Client 1 (C1), who passed away on 2/19/2024 and was reported to Community Care Licensing on 3/13/2024.

During the visit, LPA reviewed C1's file and obtained copies of the following: ID/emergency Information, Admission Agreement, Physician's reports, Inland Regional IPP, Progress/daily notes, Medication logs, medical appointments, and laboratory paperwork. LPA requested a copy of C1’s death certificate when it is made available.

C1 was admitted to hospital on 1//31/2024 for surgery.

During today's visit, no red flags were observed, and no deficiencies were cited regarding this incident.

An exit interview was conducted, and a copy of this report was provided to Care Giver Ana Bell .
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
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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