374603719-8-19-2025-08-AS-THOS-DKPP9Z-20250819110759

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603719
Report Date: 08/19/2025
Date Signed: 08/19/2025 11:08:05 AM

Document Has Been Signed on 08/19/2025 11:08 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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	EUBANK RANCH		FACILITY NUMBER:	374603719
ADMINISTRATOR/ DIRECTOR:	DE LA ROSA, ANETA		FACILITY TYPE:	735
ADDRESS:	9978 EUBANK LANE		TELEPHONE:	(619) 804-1568
CITY:	SPRING VALLEY	STATE: CA	ZIP CODE:	91977
CAPACITY: 6		CENSUS: 5	DATE:	08/19/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:39 AM
MET WITH:	Analicia Tavarez, House Manager & Licensee, Michael Stanek		TIME VISIT/ INSPECTION COMPLETED:	11:15 AM

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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Analicia Tavarez, House Manager. Licensee, Michael Stanek arrived during the visit.

During today’s visit, LPA briefly toured the facility, collected and reviewed care records on Client 1(C1), and interviewed staff. LPA performed a welfare check on the clients in care, finding no immediate safety concerns.

Today's visit was in response to Licensee’s self-reported death of Client #1 (C1), received at the CCLD San Diego Regional Office on 08/18/2025. Per the report, C1 had an incident of choking on 08/07/2025 while eating breakfast. Interviews revealed the staff that was at the facility with the client performed the Heimlich maneuver on C1 and was unable to dislodge the food to clear the airway. The staff called 911 and started to immediately follow 911 dispatch's instructions. Interviews revealed the staff started CPR while on the phone with 911 and did CPR until the paramedics arrived. C1 was then transported to the hospital.

Interviews revealed that C1 was in good/normal health that day, with no sign of illness, coughing, and that the choking began while eating breakfast. C1 was hospitalized and in the ICU for further monitoring. C1 passed away at the hospital on 08/17/2025 due to no positive change in C1s condition and was pronounced with having cardiac death.

During a review of records, LPA observed and manager interview confirmed: C1 began eating breakfast around 6:50 am before leaving for program around 8am. Licensee possess a completed LIC 602 Physician’s Report dated 11/26/2024 on C1, as was required. C1s documented diagnosis is Developmental Delay and Schizophrenia.

No deficiencies seen or cited during todays visit.

An exit interview was conducted with Licensee, Michael Stanek, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Tiffany Holmes
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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