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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600825
Report Date: 10/08/2021
Date Signed: 10/08/2021 03:36:06 PM

Document Has Been Signed on 10/08/2021 03:36 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 DR #100
MONTERY PARK, CA 91754
FACILITY NAME:DIANA'S HOMEFACILITY NUMBER:
191600825
ADMINISTRATOR:RENTERIA, DIANA LEEFACILITY TYPE:
735
ADDRESS:827 GIAN DRIVETELEPHONE:
(310) 533-5128
CITY:TORRANCESTATE: CAZIP CODE:
90502
CAPACITY: 6CENSUS: 3DATE:
10/08/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:DIanae Renteria-LicenseeTIME COMPLETED:
03:45 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
Licensing Program Analyst (LPA) Stephanie Cifuentes initiated a case management visit regarding an incident reported to CCL on 10/8/2021. LPA arrived at 1:00pm and called Eve Tighe to complete facility risk assessment. LPA informed staff that the reason for the visit was due to the incident which occurred on 10/8/2021 and was allowed entry.

During todays’ visit LPA interviewed administrator, staff and toured physical plant. On 10/8/2021 client 1 (C1) was found by staff 1 (S1) on floor of bathroom. S1 went to get administrator, who attended to client, while S1 called police and paramedics. Cause of death was deemed natural causes.

LPA requested the following documents: Staff roster, staff schedule, IPP, IBSP and Physicians Assessment for C1.

A request was made to provide a copy of the death certificate when it becomes available.

No deficiencies will be cited at this time, additional investigation is required which includes analysis of the records obtained and follow up interviews.

Exit interview held and a copy of report provided to administrator Diana Renteria.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2021
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