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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200735
Report Date: 10/26/2023
Date Signed: 10/26/2023 03:43:16 PM

Document Has Been Signed on 10/26/2023 03:43 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:CALIFORNIA MENTOR - MALABAR HOMEFACILITY NUMBER:
019200735
ADMINISTRATOR:JOSEPH FARRISH IIIFACILITY TYPE:
740
ADDRESS:4639 MALABAR AVETELEPHONE:
(909) 483-2505
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY: 4CENSUS: 4DATE:
10/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH: Abigail Cruz, Program Supervisor TIME COMPLETED:
04:00 PM
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On 10/26/2023 Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced case management visit regarding a self-reported incident that occurred on 10/18/23. LPA spoke with Program Supervisor, Abigail Cruz and explained the purpose of the visit.

LPA received a special incident report regrading a client that wasn’t giving medication at the time that was being prescribed. During the investigation LPA interview S1, reviewed and obtained C1 medication record, C1 changing in condition, and review staff training record that was stating on the special incident report.

No deficiencies cited. Exit Interview conducted and a copy of this report provided via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2023
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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