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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604219
Report Date: 03/08/2022
Date Signed: 03/08/2022 12:09:50 PM

Document Has Been Signed on 03/08/2022 12:09 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:REAL HOMEFACILITY NUMBER:
374604219
ADMINISTRATOR:QUITEVIS, JHODEEFACILITY TYPE:
734
ADDRESS:2281 RITTER PLACETELEPHONE:
(650) 238-4987
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY: 5CENSUS: 2DATE:
03/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jhodee Quitevis, AdministratorTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility following receipt of a death report involving Client One (C1). The LPA met with Administrator, Jhodee Quitevis, and informed her of the purpose of the visit.

A Death Report was received by the Riverside Regional Office on March 04, 2022. The report indicates C1 passed away on March 01, 2022 from Cardiac Arrest. The report indicates C1 was noted to have been unresponsive while in bed at approximately 7:57 PM. Facility staff contacted emergency medical personnel (911) and provided the client resuscitative measures until 911 arrival at 8:05 PM. C1 was later transferred to a local hospital where they later passed at approximately 8:38 PM. Administrator Quitevis reported hospital personnel reported C1's cause of death was from Cardiac Arrest. Quitevis also reported C1 had a scheduled appointment with a Cardiologist on April 12, 2022.

No health and safety concerns were observed at time of visit. This report was reviewed with Quitevis and a copy was provided.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2022
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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