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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602644
Report Date: 10/05/2023
Date Signed: 10/05/2023 03:50:31 PM

Document Has Been Signed on 10/05/2023 03:50 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CATSPAW PLACEFACILITY NUMBER:
374602644
ADMINISTRATOR:CUARESMA, MELANIEFACILITY TYPE:
735
ADDRESS:1154 CATSPAW PLACETELEPHONE:
(760) 658-6438
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY: 6CENSUS: 5DATE:
10/05/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH:Julita Ramirez - LicenseeTIME COMPLETED:
04:01 PM
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced Case Management Incident visit. LPA was greeted and granted entry by Licensee Julita Ramirez. LPA explained the purpose of the visit and toured the facility. The visit is in response to the death of Client One (C1), whom passed away on 10/03/2023.

During LPA's visit, LPA reviewed C1's file and obtained copies of the following: ID/emergency Information, admission agreement, Physician's reports, Psychiatric notes, Functional Capabilities Assessment, Individual Program Plan, progress notes, and medication records (MARs) for the last 30 days. LPA also requested a copy of C1s death certificate when it is made available.

During today's visit no deficiencies were cited in regard to this incident.

An exit interview was conducted, and a copy of this report was provided to Licensee Julita Ramirez along with a copy of the LIC 811.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
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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