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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191870390
Report Date: 10/12/2023
Date Signed: 10/17/2023 07:12:40 AM


Document Has Been Signed on 10/17/2023 07:12 AM - 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:MITCHELL GROUP HOMEFACILITY NUMBER:
191870390
ADMINISTRATOR:BARBARA KIZZIEFACILITY TYPE:
735
ADDRESS:1202 WEST 101ST ST.TELEPHONE:
(323) 754-1408
CITY:LOS ANGELESSTATE: CAZIP CODE:
90044
CAPACITY:6CENSUS: 8DATE:
10/12/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:47 PM
MET WITH:Stephanie Weathersby TIME COMPLETED:
03:59 PM
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On 10/12/23, 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 Stephanie Weathersby 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 who reported the death of (C1) on 10/05/23. The death report stated that (CI) passed away on 10/04/23 at around 10:00 a.m. in Centinela Hospital. According to the incident report (C1) was observed by staff and reported that (C1) did not completely eat breakfast and appeared to not feel well. (C1) remained at home who laid down and rested until lunch. After eating lunch, (C1) appeared to be restless, having difficulty sitting up and breathing became labored. Weathersby contacted 911 and paramedics arrived at the facility and started treating (C1). After treatment by paramedics, (C1) was transported to the hospital and later a family member called the facility and reported (C1) passed away. A Certificate of Death received 10/11/23, revealed the immediate cause of death is Acute Myocardial Infraction, Coronary Artery Disease, Chronic Atrial Fibrillation and Cardiomyopathy.

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

Based on information gathered, the Department found no evidence of negligence or foul play by the facility and will now close this investigation. An exit interview was conducted with Stephanie Weathersby and a hard copy was provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
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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