<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600521
Report Date: 12/05/2022
Date Signed: 12/05/2022 05:04:41 PM

Document Has Been Signed on 12/05/2022 05:04 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:KAISER SPECIALIZED RESIDENTIAL ALHAMBRAFACILITY NUMBER:
198600521
ADMINISTRATOR:MASAYON, HIRAMOWEN (OWEN)FACILITY TYPE:
735
ADDRESS:1101 GERANIO DRTELEPHONE:
(626) 665-1080
CITY:ALHAMBRASTATE: CAZIP CODE:
91801
CAPACITY: 4CENSUS: 3DATE:
12/05/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ariel De La Cruz, House LeadTIME COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit in response to a death report that was submitted to CCLD on 11/25/22. LPA met with the House Lead, Ariel De La Cruz, and explained the purpose of the visit.

The death report indicated that Client #1 (C1) passed away at the hospital on 11/25/22 at 12:43 a.m. LPA conducted interviews with the Administrator and 3 Staff. Per interviews, on 11/23/22, the facility obtained results for C1 who tested positive for COVID-19, along with another client in the home. Staff kept close monitoring of C1 and checked vitals throughout the day and night. There were no signs of distress nor COVID-19 symptoms coming from C1. Due C1's uncontrollable movements and could not obtain accurate oxygen level readings which fell below 90%, the Administrator instructed the NOC shift staff to contact 911 on 11/24/22 at approximately 5 a.m. The paramedics came and took C1 to the hospital. Per the Administrator, the vitals taken at the hospital were within normal range and C1 had an oxygen level of 96%. However, C1 went into cardiopulmonary arrest at the hospital and resuscitation was attempted on 11/25/22.

LPA requested for the following documents:
* Face Sheet, MAR log for September through November 2022, IPP, Physician's Report, and death certificate.
LPA did not note any deficiencies during the visit today. An exit interview was conducted and a copy of this report was provided to the house lead.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1