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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600002
Report Date: 08/02/2024
Date Signed: 08/02/2024 02:52:47 PM

Document Has Been Signed on 08/02/2024 02:52 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:MOUNTAIN VIEW CAREFACILITY NUMBER:
198600002
ADMINISTRATOR/
DIRECTOR:
CAROLINE TANFACILITY TYPE:
735
ADDRESS:2622 MOUNTAIN VIEW ROADTELEPHONE:
(626) 448-1682
CITY:EL MONTESTATE: CAZIP CODE:
91732
CAPACITY: 83CENSUS: 76DATE:
08/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Caroline TanTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Glenn Trueman visited this facility as an unannounced Case Management Visit in connection to a Death Report received on: 7/29/2024 from the above facility, detailing the events of: 07/28/2024. LPA Trueman met with Administrator Caroline Tan and the purpose for the visit was discussed.

During the course of the visit, LPA reviewed Client 1's file. Various documents were submitted to Licensing on 07/29/2024 which included Physician's Report, Emergency ID, Medication Log ,and Needs and Services Plan.
LPA interviewed Administrator Caroline Tan at today's visit. The administrator stated that Client 1 had not returned to the facility since entering the hospital on 07/02/2024.
Death Report was submitted on 07/29/2024 and it states that on 07/02/2024, client was sent to the CA Hospital of Hollywood due to knee pain and unable to walk. Client was diagnosed with osteosarcoma and was transferred to Cedar Sinai Hospital for surgery and chemotherapy. 07/13/2024, test results show cancer is elevating. 07/14/2024, hospital reported to facility that client is in critical condition.. 07/28/2024, per the client's brothers request the hospital removed clients oxygen mask and client was scheduled to be admitted to hospice the next day, but passed away later in that day.

Administrator will submit Death Certificate when received from family.
There was no police or coroner involved in this case.
Based on the available information reviewed, further investigation is needed.

Exit interview conducted with Administrator and copy of report provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2024
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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