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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423474
Report Date: 07/07/2020
Date Signed: 07/08/2020 11:05:25 AM

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:VALLEY CRESTFACILITY NUMBER:
366423474
ADMINISTRATOR:JORDAN, KIMBERLYFACILITY TYPE:
740
ADDRESS:18524 CORWIN RDTELEPHONE:
(760) 242-3188
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY:65CENSUS: 44DATE:
07/07/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:07 PM
MET WITH:Kimberly Jordan - AdministratorTIME COMPLETED:
04:23 PM
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Licensing Program Analyst (LPA) Natalie Gayoso contacted the facility to initiate a case management visit via telephone due to COVID-19. LPA identified herself and discussed the purpose of the call with administrator, Kimberly Jordan.

LPA received an incident report regarding the death of Resident #1 (R1). LPA interviewed the administrator and staff in regards to the events that led to the death of R1.

LPA requested the following documents for review of R1’s file:

· Emergency/Identification Information
· Physicians Report
· Behavior Reports/Notes
· Needs and Services Plan
· Medication Administration Record (MAR) of R1

LPA requested a copy of the death certificate and medical records as soon as they become available.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed via telephone and a copy sent to Ms. Jordan via email.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie GayosoTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2020
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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