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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426867
Report Date: 03/02/2022
Date Signed: 04/13/2022 03:13:24 PM

Document Has Been Signed on 04/13/2022 03:13 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
RIVERSIDE, CA 92507
FACILITY NAME:HACIENDA CAREFACILITY NUMBER:
366426867
ADMINISTRATOR:LAYGO, ANITAFACILITY TYPE:
735
ADDRESS:13874 CHOCO RDTELEPHONE:
(760) 946-2033
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 6CENSUS: 5DATE:
03/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Manager- Rafina Laygo TIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Bernadette Allen an unannounced case management visit to this facility to follow up on an Special Incident Report (SIR) received in the Regional Office 2/28/22 regarding Client 1's (C1) death. LPA met with house managers Jason Laygo and Rufina Laygo .

LPA discussed the purpose of the visit and obtain additional information regarding the client's death. LPA reviewed C1’s facility file. LPA obtained copies of the following documents: Client ID/emergency information, admission's agreement, physician's report, Individual Program Plan (IPP), daily notes, special incident reports, and death report.

The Department is requesting a copy of C1's death certificate once it becomes available. Further investigation may be required depending on the cause of death.

No deficiencies were cited during the visit. An exit interview was conducted where this report was discussed and provided to the manager Jason Laygo.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2022
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HACIENDA CARE
FACILITY NUMBER: 366426867
VISIT DATE: 03/02/2022
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SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
LIC809 (FAS) - (06/04)
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