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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604321
Report Date: 08/11/2022
Date Signed: 08/11/2022 04:49:05 PM

Document Has Been Signed on 08/11/2022 04:49 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:SANTA FAUSTINA ARFFACILITY NUMBER:
374604321
ADMINISTRATOR:BEALS, SUSANFACILITY TYPE:
735
ADDRESS:227 BAVARIA DRTELEPHONE:
(760) 806-9616
CITY:VISTASTATE: CAZIP CODE:
92083
CAPACITY: 6CENSUS: 5DATE:
08/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Arlene Escalona, AdministratorTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA), Stephanie Torres, made an unannounced visit to follow up on the notification of the death of Client One (C1). A health and safety check, relating to complaint #18-AS-20220811094626, was also conducted. The LPA met with House Manager, Arlene Escalona, and informed her of the purpose of her visit.

The Department was informed of C1's death via telephone call from Licensee, Susan Beals, on August 11, 2022. LPA Torres arrived to the facility, toured the home, conducted staff/resident interviews, reviewed records, and took copies of pertinent documentation. Staff interviews reported C1 was found on the floor of the restroom, was visibly injured and was calling for assistance. Staff reported they could not enter the bathroom to provide assistance, due to the client lying on the floor and against the door. It was reported emergency personnel (911) were immediately contacted and arrived within twenty to thirty minutes. Interviews revealed emergency personnel reported C1 passed away at the facility. The cause of death was not reported to staff by personnel who attended to the client.

Further investigation as to the cause of death for C1 will continue and any warranted follow up visits may be conducted, if needed. No health and safety concerns were observed at time of visit. This report was reviewed with Escalona and a copy was provided.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2022
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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