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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423843
Report Date: 10/03/2024
Date Signed: 10/03/2024 12:12:53 PM

Document Has Been Signed on 10/03/2024 12:12 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:FORTUNE CARE CENTERFACILITY NUMBER:
366423843
ADMINISTRATOR/
DIRECTOR:		LAYGO, ARCELIAFACILITY TYPE:
735
ADDRESS:22328 BROKEN LANCE RDTELEPHONE:
(760) 247-7925
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 6CENSUS: 4DATE:
10/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Blesilda VicerraTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to follow-up on a incident reported on 9/10/24 involving client #1 (C1). LPA met with Blesilda Vicerra, DSP, and was granted entry into the facility.

LPA conducted interviews with staff and clients. Interviews reveal that C1 was not manually restrained and scratches to their knee occurred during a fall outside of the facility.

An exit interview was conducted where this report was discussed and copy provided to the DSP.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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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