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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601190
Report Date: 12/26/2024
Date Signed: 12/26/2024 04:43:44 PM

Document Has Been Signed on 12/26/2024 04:43 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:REAL GUEST HOME OF NORTH COUNTYFACILITY NUMBER:
374601190
ADMINISTRATOR/
DIRECTOR:
AIMEE CABILINGFACILITY TYPE:
735
ADDRESS:1225 E. PENNSYLVANIA AVENUETELEPHONE:
(760) 291-1349
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 49CENSUS: 17DATE:
12/26/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Licensee Aimee CabilingTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Armando Perez made an unannounced visit to conduct a case management visit to follow up on a client's death. LPA met with Licensee Aimee Cabiling (S1) and explained the purpose of today's visit. LPA was informed that Client#1(C1) was last seen at the facility on December 15, 2024 and was missing until he was found sitting unresponsive in his room on the morning of December 17, 2024.

During the visit LPA reviewed and collected pertinent documentation such as: ID/Emergency information, Admission Agreement, Physicians report, Medication records, service plan, as well as conducted staff interviews in regards to the death of C1. LPA interviewed Licensee Aimee Cabiling, Staff (S2) and client 2 (C2) for further information in regards to the death of C1 and the events that led up to C1's death. C1's medications were reviewed, LPA observed MAR records are not available or utilized at the facility.

LPA inquired about the cause of the death. A death certificate has not been issued at this time. Additionally, the preliminary cause of death is still being determined. LPA advised to send a copy of the death certificate to the regional office once received.

Licensee did not contact Community Care Licensing until a faxed Incident report and death report was submitted on December 23, 2024. LPA informed Licensee to reiterate the time frame requirements and the importance of communicating in a timely manner to avoid deficiencies.

An exit interview was conducted, a copy of this report was provided to Licensee Aimee Cabiling. .
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE: DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2024
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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