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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197600960
Report Date: 05/31/2022
Date Signed: 05/31/2022 12:01:34 PM

Document Has Been Signed on 05/31/2022 12:01 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:AIZABEL HOMEFACILITY NUMBER:
197600960
ADMINISTRATOR:TOLENTINO, MARIA LILIANFACILITY TYPE:
735
ADDRESS:1425 ETHEL ST.TELEPHONE:
8185453975
CITY:GLENDALESTATE: CAZIP CODE:
91207
CAPACITY: 6CENSUS: 4DATE:
05/31/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Maura Panganiban TIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Calderon and LPA Pena conducted an unannounced initial case management visit regarding the death of client #1 (C1) which occurred on on 5/24/22. LPAs met with staff Administrator Maura Panganiban and explained the reason of the visit .

During today's visit C1's file was reviewed and obtained the following:
  • Staff roster and Client's roster
  • C1 face sheet (LIC 601)
  • Copy of Weekly Food Menu
  • Most recent Physician Report - April 28 , 2022
  • Name of Police Office and Contact Information : Glendale Police / Phone #
  • Medication Administration Records
  • P&I Ledgers
  • List of Personal Belongings
  • Dental Report

On 5/24/22 LPA Calderon received an incident report in which the death of C1 was reported. The same day of death LPA Calderon obtained C1's Death Report, Consumer Information Sheet, Individual Program Plan (IPP), Medication Sheet Log for months , March, April and May 2022.

During today's visit LPA's interviewed the Administrator S1 , DSP worker S2 , C1s roommate (C2) and clients Mother. Mother whom is the conservator will provide the police report, death certificate and autopsy when they become available.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2022
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: AIZABEL HOME
FACILITY NUMBER: 197600960
VISIT DATE: 05/31/2022
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LPAs toured physical plant , kitchen , dinning area and C1's bedroom ,backyard, no concerns were observed.

Further Investigation is required and will return at a further time. Exit interview was conducted and a copy of the report was provided to staff.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022
LIC809 (FAS) - (06/04)
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