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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803708
Report Date: 05/06/2024
Date Signed: 05/06/2024 01:48:41 PM

Document Has Been Signed on 05/06/2024 01:48 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:BURTREE RESIDENTIAL FACILITYFACILITY NUMBER:
197803708
ADMINISTRATOR/
DIRECTOR:
LAMAUIG, JOYCELYNFACILITY TYPE:
735
ADDRESS:16422 BURTREE STREETTELEPHONE:
(626) 363-4162
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 6CENSUS: 5DATE:
05/06/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Administrator Joycelyn LamauigTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Jose Villalobos initiated a Case Management visit to conduct a health and safety check regarding a client death reported. LPA met with Administrator Joycelyn Lamauig and the purpose of the visit was discussed.

Licensing received a death report for Client #1 (C1) on 3/26/24. Death occurred in the facility on 3/25/24 in the morning around 7:40am. C1 was found unresponsive in the living by another client and 911 was contacted. Administrator provided CPR until paramedics arrived but C1 was pronounced deceased. Suspected cause of death is cardiac arrest. Prior to visit, LPA Villalobos acquired and reviewed C1s (C1) Physicians Report, Needs and services Plan, Identification and Emergency Information, Intake Assessment and Death Report. Facility unable to provide Licensing a death certificate as C1's family does not wish to provide it to the facility.

On todays visit LPA conducted a health and safety check. LPA toured the physical plant of the facility and did not observe any blocked passageways or health and safety hazards. LPA observed the food supply to have 7 days worth of non perishables and 2 days worth of perishables available. LPA observed toxins and sharps were locked and inaccessible to clients in care. Water temperature measured within Title 22 regulations.

No deficiencies are being cited at this time. Facility was advised to work on acquiring a death certificate from C1s family and provide to Licensing.

LPA conducted exit interview and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2024
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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