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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426704
Report Date: 03/11/2024
Date Signed: 03/11/2024 12:06:39 PM

Document Has Been Signed on 03/11/2024 12:06 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:KENNETH ADULT RESIDENTIAL VFACILITY NUMBER:
366426704
ADMINISTRATOR:CHAVEZ, SYLVIAFACILITY TYPE:
735
ADDRESS:6251 BRECKINRIDGE LN.TELEPHONE:
(909) 464-9460
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY: 6CENSUS: DATE:
03/11/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Rosa Olibares, AdministratorTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a case management visit regarding a client death. LPA Prieto met with Administrator Rosa Olibares and discussed the elements of the visit. Client #1 was last at the facility on March 6, 2024. 911 was called and C1 was transported to a medical facility where C1 was in ICU. Facility staff arrived to the medial facility at approximately 8:30 AM on March 7, 2024. Medical staff stated to facility staff #1(S1), the C1 was doing OK. Approximately, 10 minutes later, medical staff performed CPR for approximately 25 minutes later medical staff declared C1 had passed away. Medical staff stated to S1 that C1 had not given a definitive cause of death at this time.

LPA obtained residents records that included Physician report, Primary Care Physician visit summaries for February and January 2024, Psychiatric reports, Pulmonary report, C1 daily reports leading to C1's hospital visit and subsequent passing.

C1 passed away under the care of the medical facility. Final doctor's summary of the death are yet to be released to the facility staff or family members. Primary Physician had seen C1 in January and February of 2024 and the last reports were obtained by LPA Prieto during this visit.

This report was signed by LPA Prieto and Administrator Olibares and a copy was left at the facility.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2024
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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