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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603739
Report Date: 02/08/2024
Date Signed: 02/08/2024 04:11:04 PM

Document Has Been Signed on 02/08/2024 04:11 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MENTONE HOUSEFACILITY NUMBER:
197603739
ADMINISTRATOR:ROBIN PHILLIPSFACILITY TYPE:
735
ADDRESS:1980 MENTONETELEPHONE:
(626) 398-5629
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 6CENSUS: 4DATE:
02/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Maggie Estrada - AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced Case Management Visit to follow up on a Death Report faxed to the Department on 2/7/24. LPA met with Administrator Maggie Estrada and explained the reason for the visit.

On 2/6/24 around 7am a staff member (Staff #1/S1) observed Client #1 (C1) sleeping/snoring while doing rounds, S1 exited room to assist another client and shortly after checked on C1 again to wake C1 up for the day, S1 was unable to wake up C1 after several attempts, S1 had staff call 911 and a nurse for another client that was at the facility at the time began to administer CPR, CPR was being administered as paramedics arrived and they took over, C1 was sent to hospital and expired at hospital on 2/6/24.

During today's visit LPA interviewed the Administrator and S1, obtained copies of C1's FACE Sheet, Death Report, Appraisal Needs & Services Plan, Physician's Report, and Medication Administration Record (MAR) for December 2023--February 2024.

LPA also toured C1's bedroom. No concerns, obstructions, or anything out of the ordinary was witnessed during the visit. LPA has also requested facility to obtain and provide Licensing with C1's Death Certificate upon receipt.

No deficiencies observed during today's visit. Exit interview held and a copy of the report was provided to Administrator Maggie Estrada.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2024
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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