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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366412346
Report Date: 03/07/2023
Date Signed: 03/07/2023 04:28:49 PM

Document Has Been Signed on 03/07/2023 04:28 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:KENNETH ADULT RESIDENTIAL IIIFACILITY NUMBER:
366412346
ADMINISTRATOR:CHAVEZ, JAMESFACILITY TYPE:
735
ADDRESS:12379 LORAINE AVE.TELEPHONE:
(909) 364-0137
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY: 6CENSUS: 4DATE:
03/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Rosa OlibaresTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a case management visit regarding a death at the facility. Client #1 was last at the facility on February 19th, 2023 and sent to a medical facility, via 911 call and later passed at the medical facility 13 days later. LPA obtained residents records that included Physician report, IPP reports, doctor's notes and daily notes leading up to the day of the 911 call and subsequent passing. C1 passed away under the care of the medical facility. Final doctor's summary of the death are yet to be released and yet to be received by the facility. C1 had monthly televisits by their Primary Physician and the last report was obtained by LPA Prieto during this visit. There was no evidence to during today's visit nor witness interview to conclude that the facility added or contributed to C1's passing.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2023
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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