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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423843
Report Date: 09/23/2021
Date Signed: 09/23/2021 10:14:06 AM

Document Has Been Signed on 09/23/2021 10:14 AM - 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:FORTUNE CARE CENTERFACILITY NUMBER:
366423843
ADMINISTRATOR:LAYGO, ARCELIAFACILITY TYPE:
735
ADDRESS:22328 BROKEN LANCE RDTELEPHONE:
(760) 247-7925
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 6CENSUS: 4DATE:
09/23/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Arcelia LaygoTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Natalie Gayoso conducted an in-office case management meeting and met with Administrator Arcelia Laygo.
The purpose of today’s visit was to discuss the investigative findings pertaining to the death of Client #1, (C1).

It was alleged that Client #1 (C1) died due to possible neglect and lack of supervision. On 9/28/20 the department received notification that Client #1 (C1) was struck by a car after being discharged from the hospital. The department’s investigation into C1’s death included file review, interviews with staff/residents/witnesses, and collecting pertinent records.

On September 25, 2020 at 5:20pm C1 was transported to the hospital due to an injury to the right leg. C1 was transported by ambulance alone due to Covid-19 restrictions. At 6:30pm hospital personnel informed the facility that C1 was ready for discharge and facility staff was scheduled to be there in 20 minutes. At 7:10pm C1 screamed during discharge and ran out of the hospital. The RN was unable to apprehend C1 but hospital security chased C1. C1 was seen crossing the Highway. When facility staff arrived at the hospital, they were directed towards the direction were C1 went. The hospital called the police and facility staff started searching for C1. Facility staff was later informed that C1 was struck by a car and killed. Based on the investigation the allegation questionable death due to lack of care is unfounded. The department has found that the allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis.

No deficiencies were sited at this time.
An exit interview was conduct, and a copy of this report was provided to the Administrator
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Natalie Gayoso
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2021
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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