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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801709
Report Date: 05/23/2023
Date Signed: 05/23/2023 01:37:33 PM

Document Has Been Signed on 05/23/2023 01:37 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:ROSEMEAD VILLAFACILITY NUMBER:
197801709
ADMINISTRATOR:PASCASIO, ZOSIMOFACILITY TYPE:
735
ADDRESS:9025 GUESS STTELEPHONE:
(626) 280-4375
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 28CENSUS: 26DATE:
05/23/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Staff / Caren Tanalega
Administrator / Zosimo Pascasio		TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced case management visit to this facility. Upon arriving at the facility, LPA met with Staff / Caren Tanalega and was later joined by the Administrator / Zosimo Pascasio, who assisted with the visit. LPA explained the purpose of today’s visit is to gather additional details surrounding the death of Client #1 (C1), which occurred on 5/16/23.

According to the Death Report, on 5/16/23, around 5pm, Staff #1 (S1) went to Room 3 to let C1 know that it was dinner time. S1 was unable to open the door of C1, as the door was stuck. S1 and a few other clients helped push the door open, at which time found C1 lying on the floor unresponsive. C1's body was located behind the door, beside a chest of drawers that had fallen on him. C1 had an electrical cord tied around his neck. Staff immediately called 911 and officers along with detectives from the Temple City Sheriff's Department arrived on scene.

During today's visit, LPA was unable to review the file of C1. The Administrator stated that the Temple City Sheriff's Department confiscated the file of C1 and the file has not been returned back to the facility. LPA requested copies of the following documents to be faxed to CCL, by no later than 10am, on 5/24/23.

• Identification and Emergency Information • Physician's Report • Appraisal/Needs and Services Plan
• Admission Agreement • Temple City Sheriff's Report • Resident Appraisal • Medication Administration Record (MAR) • Consent Forms

The Administrator will also forward copies of the Coroner's Report and Death Certificate to CCL, upon obtaining copies.
LPA will return on a later date once all requested documentation is obtained and reviewed in order to close this case.
An exit interview was conducted and a copy of this report was provided to the Administrator.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2023
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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