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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600002
Report Date: 02/04/2025
Date Signed: 02/04/2025 03:30:06 PM

Document Has Been Signed on 02/04/2025 03:30 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: 78DATE:
02/04/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Staff Aristotle TanTIME VISIT/
INSPECTION COMPLETED:
03:45 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: 01/31/2025 from the above facility, detailing the events of: 01/30/2025. LPA Trueman met with Staff Aristotle 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 01/31/2024 which included Physician's Report, Emergency ID, Medication Log ,and Needs and Services Plan.
LPA interviewed Staff Aristotle Tan at today's visit. The Staff Aristotle Tan stated that Client 1 in morning around 850 AM Med staff told him to check Client 1 in his room. Was very pale. Said he had chest pain and trouble breathing. He said last nite around 11 PM he felt it.
Oxygen low. He called 911 and then they sent him to Greater El Monte.

Death Report was submitted on 01/31/2025 and it states that on 01/29/25 Client C1 had complained of chest pain, shortness of breath and looked pale.
Client was admitted to Greater El Monte hospital with diagnosis of pneumonia, Sepsis, Hypoxia, Tachycardia, Respiratory failure, on oxygen of 6L.
Client was seen on 01/14/25 by his provider and was given antibiotic and cough medicine for Bronchitis.
On 01/30/25 Case Manager called and notified the client had expired at 12:30 PM.

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 Staff Aristotle Tan.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
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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