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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204972
Report Date: 08/23/2023
Date Signed: 08/23/2023 03:47:19 PM


Document Has Been Signed on 08/23/2023 03:47 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:ROSECRANS VILLA RESIDENTIAL CAREFACILITY NUMBER:
198204972
ADMINISTRATOR:SANDRA LOPEZFACILITY TYPE:
740
ADDRESS:14110 CORDARY AVENUETELEPHONE:
(310) 675-9163
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY:135CENSUS: 112DATE:
08/23/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:52 PM
MET WITH:Sandra LopezTIME COMPLETED:
03:45 PM
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On 08/23/23, Licensing Program Analyst, Wendy Gibbs, conducted an unannounced case management visit to follow up on the death report of Resident 1 (R1). LPA Gibbs met with Administrator, Sandra Lopez, and explained the purpose of today's visit.
The Regional Office received a copy of the death report from the facility who reported the death on 08/22/23 at 10:48am. The death report stated that during lunch on 08/14/23 at 12:20pm, in the dining room, R1 began to choke on a piece of hot dog. Staff 1 (S1) began to do the Heimlich Maneuver. The LVN (S2) on duty came to assist by continuing the Heimlich Maneuver and then giving CPR. Paramedics arrived at the facility, took over CPR, and at 12:45 transported R1 to the hospital. On 08/19/23 at 8:42pm, the resident died at the hospital. The Administrator was notified on 08/21/23 by the R1's Public Guardian. On the death report, submitted by the facility, the cause of death is due to complications from choking incident. R1's Public Guardian requested the medical records from the hospital and the Administrator is awaiting the records. Administrator stated they will send the medical records and death certificate to CCL when they receive them.

During today's visit LPA Gibbs and Administrator toured the facility. LPA Gibbs received and reviewed the following documents:


-Identification & Emergency Information -Penn Mar Healthcare Center (PMHC) Interdisciplinary
-Preplacement Appraisal Information Discharge Summary
-Physician's Report -PMHC Notice of Transfer/Discharge
-Appraisal/Needs & Services Plan -PMHC Patient Information Sheet & Administrative Information
-MAR -PMHC Nursing Services, Medication Consent & MAR
-Patient Vital Sign/Diabetic Flow Sheet -PMHC Insulin Sliding Scale
-Regular Insulin Sliding Scale AC Breakfast -PMHC Rehabilitation/Recreation Therapy
-Special Incident Report
-Facility Menu

No deficiencies were observed or cited during today's visit.


An exit interview was conducted with Administrator, Sandra Lopez and a copy of this report was provided.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023
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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