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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600333
Report Date: 03/13/2023
Date Signed: 03/13/2023 03:32:44 PM

Document Has Been Signed on 03/13/2023 03:32 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:C-H #2 COMMUNITY LIVING RESIDENTIAL FACILITYFACILITY NUMBER:
191600333
ADMINISTRATOR:DAVID BERRYFACILITY TYPE:
735
ADDRESS:3220 W 111TH PLTELEPHONE:
(310) 419-7434
CITY:INGLEWOODSTATE: CAZIP CODE:
90303
CAPACITY: 6CENSUS: 2DATE:
03/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:29 AM
MET WITH:Elsa Rodriquez TIME COMPLETED:
03:49 PM
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On 03/13/23 Licensing Program Analyst, LPA Ernand Dabuet conducted a Case Management visit to follow up on the death reported for Client #1 (C1). LPA was greeted by Elsa Rodriquez care staff who contacted David Berry administrator by telephone. LPA spoke with Berry and explained the purpose of the visit was to gather information surrounding the death of (C1).

The regional office received a copy of the death report from the facility and reported the death of (C1) on 03/02/23. The death report stated that approximately at 9:00 pm on 02/28/23 (C1) was found by staff #4 (S4) with breathing was not normal on 02/26/23. Paramedics was dispatched and determined (C1's) blood pressure was low. The paramedics transported (C1) to Centinela Hospital and was held for observation. A family member contacted the administrator on 03/01/23 at 8:40am that (C1) was declared dead from natural causes.

The following documents were requested:
  • ID and Emergency Information,
  • Admission Agreement
  • Physical Health Intake Assessment,
  • Physician Report for Community Care Facilities,
  • Medications (MAR)

An exit interview was conducted with David Berry and a hard copy was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2023
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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