198600583-10-10-2023-28-AS-BPEA-CWGKRT-20231010080829

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600583
Report Date: 08/08/2023
Date Signed: 10/10/2023 08:08:53 AM

Document Has Been Signed on 10/10/2023 08:08 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	DE LEON HOME - BELLFLOWER		FACILITY NUMBER:	198600583
ADMINISTRATOR:	MAUREEN DELEON		FACILITY TYPE:	735
ADDRESS:	10240 VAN RUITEN		TELEPHONE:	(562) 920-3241
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY: 4		CENSUS: 3	DATE:	08/08/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	03:32 PM
MET WITH:	Rana Chapkhaneh - Administrator		TIME COMPLETED:	04:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced case management visit stemming from an incident report received by LPA M. Leon on 8/03/2023. LPA met with the Administrator, Rana Chapkhaneh and explained the purpose of the visit.

The incident report sent on 8/02/2023 notified the passing of client #1 (C1). During today’s visit, the Administrator provided the following information: C1 was last present at the facility on 5/19/2023. On 5/19/2023, the facility called 911 for C1 due to difficulty in breathing and elevated blood sugar level. After being hospitalized, C1 was transferred to the Skilled Nursing Facility. While under the care of Skilled Nursing Facility, it was made aware that C1 passed away on 7/30/2023 at 9:45pm.

Based on the interview conducted with the Administrator, it was determined that C1 was no longer a client of the facility and was not expected to return to the facility due to C1 needed a higher level of care. Additionally, the Regional Center providing services for C1 was terminated prior to C1's death.

No deficiency was issued. An exit interview was held, and a copy of this report was provided to the Administrator, Rana Chapkhaneh.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

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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