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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200735
Report Date: 06/27/2024
Date Signed: 06/27/2024 03:14:24 PM

Document Has Been Signed on 06/27/2024 03:14 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/
DIRECTOR:		JOSEPH FARRISH IIIFACILITY TYPE:
740
ADDRESS:4639 MALABAR AVETELEPHONE:
(909) 483-2505
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY: 4CENSUS: 2DATE:
06/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Joseph Gapasin, Program DirectorTIME VISIT/
INSPECTION COMPLETED:
03:25 PM
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On 6/27/2024 at 1:45PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to special incident report received on 6/24/2024. LPA met with Program Director, Joseph Gapasin and explained the purpose of the visit.

LPA received special incident report on 6/24/2024 for resident (R1). Special incident report revealed that R1 went for a walk with staff. R1 lost balance and collapse to the ground. Staff caught R1 before falling to the ground. 911 was called and R1 was sent to the hospital. R1 passed away at the hospital.

LPA interviewed staff and obtained documents including staff schedule physician's report, IPP, ISP, other SIR, and care notes.


LPA may return on a later date.


Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2024
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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