<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424320
Report Date: 08/23/2023
Date Signed: 08/23/2023 10:41:21 AM

Document Has Been Signed on 08/23/2023 10:41 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:FAUSTINA CARE CENTERFACILITY NUMBER:
366424320
ADMINISTRATOR:RUFINA C. LAYGOFACILITY TYPE:
735
ADDRESS:24888 STANDING ROCK RDTELEPHONE:
(760) 961-0188
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 6CENSUS: 4DATE:
08/23/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Care Give Josefina PasambaTIME COMPLETED:
10:50 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Mary Rico conducted an unannounced Case Management Incident visit. LPA met with Care Giver Josefina Pasamba and explained the reason for the visit. The visit is in response to the death of Client 1 (C1), who passed away on 8/18/2023.

During the visit, LPA reviewed C1's file and obtained copies of the following: ID/emergency Information, Admission Agreement, Physician's reports, Inland Regional IPP, Progress/daily notes, Medication logs , medical appointments, and laboratory paperwork. LPA requested a copy of C1’s death certificate when it is made available.

LPA spoke to C1’s family on the telephone during today’s visit, LPA was provided the cause of death based on what they were told by the hospital.

During today's visit, no red flags were observed, and no deficiencies were cited regarding this incident.

An exit interview was conducted, and a copy of this report was provided to Care Giver Josefina Pasamba.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1