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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426871
Report Date: 10/02/2024
Date Signed: 10/02/2024 11:18:00 AM

Document Has Been Signed on 10/02/2024 11:18 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PALA CARE CENTER INCFACILITY NUMBER:
366426871
ADMINISTRATOR/
DIRECTOR:		ANITA N. LAYGOFACILITY TYPE:
735
ADDRESS:24830 PALA LNTELEPHONE:
(760) 247-9241
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 6CENSUS: 2DATE:
10/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Rufina Laygo, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:25 AM
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Licensing Program Analysts (LPAs) Becky Mann, Melody Brown and Renese Howell-Small conducted an unannounced visit to the facility on 10/02/2024 at 10:00 AM to conduct a case management visit to address an incident involving an adult death that occurred on 9/28/2024.
LPAs Mann, Brown and Howell-Small met with Administrator Rufina Laygo who was informed of the purpose of the visit.

LPAs Mann, Brown, and Howell-Small requested the following documents from Client #1's (C1) file for review:
• ID/Emergency Contact Information
• Admissions Agreement
• Physician’s Report
• Doctor’s Notes/Orders
• Pre-Admission Appraisal
• Needs and Services Plan
* Individual Program Plan (IPP)
• Staff Notes
• Medication Records
• Hospital Discharge Paperwork
* Client Roster for the facility for August 2024 - Present
LPAs Mann, Brown and Howell-Small briefly interviewed Administrator Rufina Laygo and a staff regarding the circumstances leading up to C1's admission to the facility and subsequent death.
Due to this being an adult death (under the age of 60) at this facility, LPAs Mann, Brown and Howell-Small requested for Administrator Rufina Laygo to submit C1 death certificate once available.

A copy of this report was discussed and provided to Administrator Rufina Laygo
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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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