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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600145
Report Date: 05/14/2024
Date Signed: 05/14/2024 11:07:33 AM

Document Has Been Signed on 05/14/2024 11:07 AM - 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:BELL GARDENS MANORFACILITY NUMBER:
198600145
ADMINISTRATOR/
DIRECTOR:		MARIA ZUNIGAFACILITY TYPE:
735
ADDRESS:8424 S EASTERNTELEPHONE:
(562) 927-1389
CITY:BELL GARDENSSTATE: CAZIP CODE:
90201
CAPACITY: 141CENSUS: 69DATE:
05/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Maria ZunigaTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Glenn Trueman initiated a Case Management visit to conduct a health and safety check regarding a client death reported. LPA met with Administrator Maria Zuniga and the purpose of the visit was discussed.

Licensing received a death report for Client #1 (C1) on 04/29/24. Death occurred in the facility on 04/28/24 in the morning at 6:11am.
On 4/25/24, client was sent to the hospital for losing weight and was laying in bed half way when back at the facility. Staff called paramedics. Client returned on 4/27/24 around 5pm. She passed away the following morning.
At today's visit, LPA Trueman acquired and reviewed C1's (C1) Physicians Report, Needs and Services Plan, Special Incident Report (SIR) and Death Report. Facility unable to provide Licensing death certificate at this time.

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.

No deficiencies are being cited at this time. Facility was advised to work on acquiring a death certificate from C1's family and provide to Licensing.
Law Enforcement City of Bell Gardens Report #24-06470.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2024
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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