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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592599
Report Date: 11/05/2021
Date Signed: 11/19/2021 02:01:46 PM

Document Has Been Signed on 11/19/2021 02:01 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:FOUNDERS HOUSE OF HOPEFACILITY NUMBER:
191592599
ADMINISTRATOR:CRYSEL SANTOSFACILITY TYPE:
735
ADDRESS:18025 PIONEER AVE.TELEPHONE:
(562) 860-3351
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY: 98CENSUS: 82DATE:
11/05/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Dana OrdonezTIME COMPLETED:
11:15 AM
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On 11/5/2021, Licensing Program Analyst (LPA) Nina Galarza conducted a case management visit to follow up on death reported for Client #1 (C1). LPA met with Dana Ordonez, Assistant Administrator and explained the reason for the visit.

LPA received death report for client #1(C1) on 10/30/21 via email. During today's visit, LPA interviewed Assistant Administrator and C#1's room mate, Client #2 (C2). On 11/1/2021, LPA interviewed Administrator Crysel Santos telephonically. On 11/5/2021 Assistant Administrator stated on 10/29/2021 at 4:45 p.m. C1 had a change in condition, C1 developed a tremor and reported hearing voices. Facility called 911 and paramedics arrived at 4:50 p.m.; paramedics took vital signs and reported all vital signs were normal. C1 refused to go to hospital. On 10/30/2021 at 6:30 a.m. Staff 1 (S1) observed C1 unresponsive. S1 performed CPR, and facility called 911. Paramedics arrived at 6:45 a.m and also performed CPR, but resident was unresponsive. C1 was last seen by medical physician and provided an evaluation on 9/16/21, no concerns were address or noted.

The following documents were obtained on today's visit:
  • Resident roster
  • Physician's Report
  • Face sheet
  • Appraisal/ Needs and Services plan
  • Medication Administration Record (MAR) for C1, dated September 2021 - October 2021
  • Death report
  • recent doctor visit report, dated September 2021
  • recent psychiatry visit report, dated September 2021
  • refusal of treatment report, dated 10/29/2021
CONTINUED 809-C
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nina Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FOUNDERS HOUSE OF HOPE
FACILITY NUMBER: 191592599
VISIT DATE: 11/05/2021
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Facility is waiting for death certificate.

No deficiencies were observed during this visit and LPA requested Administrator to forward death certificate upon receiving it.

Exit interview was conducted with Dana Ordonez and a copy of this report was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nina Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC809 (FAS) - (06/04)
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