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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600477
Report Date: 02/23/2024
Date Signed: 02/23/2024 01:57:41 PM

Document Has Been Signed on 02/23/2024 01:57 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:CAREMORE AID & BOARD FACILITYFACILITY NUMBER:
198600477
ADMINISTRATOR:RONALD F ZABLOCKIFACILITY TYPE:
735
ADDRESS:14807 LEMOLI AVENUETELEPHONE:
(424) 269-1632
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY: 8CENSUS: 7DATE:
02/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:11 PM
MET WITH:Rolando Bundalian, CaregiverTIME COMPLETED:
02:00 PM
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On 2/23/24 Licensing Program Analyst (LPA) Felisa Shirley conducted a Case Management visit to follow up on the death reported for Client #1 (C1). LPA was greeted by Rolando Bundalian. LPA spoke with staff and explained the purpose of the visit was to gather information surrounding the death of (C1).

On 2/14/24, CCLD received a copy of the death report from the facility staff who reported the death of (C1) on 2/11/24 at 11:53am. The death report stated that staff checked on (C1) and found him unresponsive. The initial investigation did not indicate the cause of death. Staff called 911 and paramedics were dispatched and determined that (C1) had passed away.

The following documents were requested and received:

· ID and Emergency Information,
· Admission Agreement
· Physician Report for Community Care Facilities,
· Needs and Services Plan
· Mental and Physical Health Intake Assessment
· Pre-Placement Appraisal
· Report from doctor’s appointment 1/15/24
· Medications (MAR)

No deficiencies were cited during this visit.

An exit interview was conducted with Rolando Bundalian and a hard copy was provided.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2024
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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