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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366413179
Report Date: 02/08/2022
Date Signed: 02/08/2022 02:51:15 PM

Document Has Been Signed on 02/08/2022 02:51 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:ALYZA HOMEFACILITY NUMBER:
366413179
ADMINISTRATOR:FIGURACION, MARIOFACILITY TYPE:
735
ADDRESS:5062 RODEO STREETTELEPHONE:
9092703738
CITY:MONTCLAIRSTATE: CAZIP CODE:
91763
CAPACITY: 6CENSUS: 5DATE:
02/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Francis Pastorfide, AdministratorTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit to the facility. The LPA arrived at the facility to conduct a case management visit to follow up on a client death. LPA met with administrator Francis Pastorfide and explained the purpose of today's visit.

This case management visit consisted of collecting pertinent documentation and conducting staff interviews in regards to the death of Client #1 (C1). LPA interviewed Staff #1 (S1) for further information in regards to the death of C1 and the events that led up to C1's death. C1 stated that no official death certificate has been issued at this time but the preliminary cause of death is still undetermined by the local Coroner's office. LPA has advised the Administrator to send a copy of the death certificate the Community Care Licensing Division (Department) Riverside Regional Office as soon as it is available.

No deficiencies were cited during this visit. An exit interview was conducted where this report (LIC 809) and LIC 811 were discussed and provided to the Administrator.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2022
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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