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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600426
Report Date: 05/02/2024
Date Signed: 05/02/2024 02:34:36 PM

Document Has Been Signed on 05/02/2024 02:34 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:C-H #5 RESIDENTIAL FACILITYFACILITY NUMBER:
198600426
ADMINISTRATOR/
DIRECTOR:		JEFFERSON, REBEKAHFACILITY TYPE:
735
ADDRESS:14750 WIEMER AVETELEPHONE:
(562) 634-4151
CITY:PARAMOUNTSTATE: CAZIP CODE:
90723
CAPACITY: 3CENSUS: 1DATE:
05/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Rebekah Jefferson (Administrator)TIME VISIT/
INSPECTION COMPLETED:
02:49 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced case management visit at the facility. LPA Mora met with Rebekah Jefferson (Administrator) and explained the reason for the visit.

During an annual inspection on 05/02/2024, LPA Mora was made aware that Client 2 (C2) passed away on 04/17/2024. LPA Mora contacted C2's conservator and regional center service coordinator to get details and cause of death. The following information was obtained: C2 was visiting the conservator and on 03/31/2024 had a seizure in the conservator's bathroom and fell down. C2 was taken to a hospital where C2 was diagnosed with fracture ribs. C2 was eventually discharged to a skilled nursing. On 04/14/2024, C2 had another fall as a result of heart failure (according to the conservator). C2 was rushed to the hospital and was placed on ventilator. On 04/17/2024, due to no brain activity the family member made the decision to disconnect C2 from the ventilator and C2 passed away. C2's family member texted the LPA a copy of the death certificate that list Cardiopulmonary Arrest as the immediate cause of death.

Exit interview held and a copy of the report were provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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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