<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592149
Report Date: 08/18/2021
Date Signed: 08/18/2021 03:22:53 PM

Document Has Been Signed on 08/18/2021 03:22 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:LOVING CARE GUEST HOMEFACILITY NUMBER:
191592149
ADMINISTRATOR:SABIO, MARILYNFACILITY TYPE:
735
ADDRESS:15027 - 15031 BLACKWOOD STTELEPHONE:
(626) 917-2312
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 12CENSUS: 9DATE:
08/18/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Aiona Fortaleza TIME COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
While Licensing Program Analyst (LPA) Christine Wong conducted an annual required inspection in the facility and the assistant administrator Aiona Fortaleza reported the death of Client#1 (C1) on 08/13/2021 and death report was faxed to Licensing on 08/16/21. According to the assistant manager, C1's sister called the facility and reported C1's mother found C1 on the floor at the mother's house and C1 was not responding and 911 was called and pronounced dead at 8am on 08/13/21.

During today's visit, LPA was provided with the following documents of C1:
• Identification and Emergency Information
• Physician's Report
• Needs and Services Plan dated 1/21/2019
• Medication Record for August, 2021

During today's visit, LPA also interviewed assistant manager and one staff (S1) and one client (C2)
LPA advised Administrator to send a copy of the death certificate to Licensing when it becomes available.

No deficiencies were cited per California Code of Regulations, Title 22, Division 6 during this visit.
Exit interview conducted, a copy of the report was given to the assistant administrator.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1