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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426866
Report Date: 10/24/2023
Date Signed: 10/24/2023 02:39:45 PM

Document Has Been Signed on 10/24/2023 02:39 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:HELPING HEARTS VISCONTIFACILITY NUMBER:
366426866
ADMINISTRATOR:MANUAL SOTOFACILITY TYPE:
772
ADDRESS:1288 VISCONTI DRIVETELEPHONE:
(909) 260-8515
CITY:COLTONSTATE: CAZIP CODE:
92324
CAPACITY: 10CENSUS: 6DATE:
10/24/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Marie Lopez, Program DirectorTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to conduct a case management visit and follow up on an client death. LPA met with program administrator Marie Lopez who was informed of the purpose of today's visit. This case management visit consisted of collecting pertinent documentation and conducting staff interviews in regards to the death of Client 1 (C1).

On 10/23/2023, the San Bernardino Regional Office received a verbal report of a client death. During today's visit, LPA interviewed Staff 1 (S1) and Staff 2 (S2) for further information about C1 and the events that led up to their death.

No deficiency was cited during today's visit. An exit interview was conducted where this report was discussed and provided to the Administrator.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023
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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