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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423605
Report Date: 02/11/2021
Date Signed: 02/11/2021 01:15:06 PM

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:SALEM CHRISTIAN HOMES-YORBA HOMEFACILITY NUMBER:
366423605
ADMINISTRATOR:MARGARET ZWARTFACILITY TYPE:
740
ADDRESS:12420 YORBA AVETELEPHONE:
(909) 627-5774
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY:6CENSUS: 5DATE:
02/11/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Justine Guillen, Acting AdministratorTIME COMPLETED:
10:25 PM
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Licensing Program Analyst (LPA), Stephanie Torres, contacted the facility via telephone to commence a case management tele-visit due to COVID-19. The LPA identified herself and discussed the purpose of the call with Acting Administrator, Justine Guillen.

The Department received a Special Incident Report (UIR) from the Inland Regional Center (IRC) on February 09, 2021, pertaining to Resident One (R1). The SIR discussed the death of R1 on February 06, 2021, reportedly resulting from their COVID-19 positive status. The report details R1 was hospitalized on January 16, 2021 due to lethargy and being non-responsive. No further details about the incident were provided on the report.

According to Guillen, the Resident was hospitalized on January 16, 2021. She reported R1 was experiencing some symptoms, which led to the resident being transferred to the hospital via emergency medical services. She confirmed the resident did pass away on February 06, 2021 while under the care of hospital staff. Per Guillen, R1 has had several medical conditions diagnosed prior to contracting COVID-19. The LPA will review reports received from the facility and follow-up, if necessary. No health and safety concerns were observed on this tele-visit.

An exit interview was conducted with Acting Administrator Guillen via telephone and a copy of this report was provided via email. Report with facility representative signature was obtained.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021
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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