198600612-1-14-2025-28-AS-CGUZ-DCWSJW-20250114125550

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600612
Report Date: 01/14/2025
Date Signed: 01/14/2025 12:55:53 PM

Document Has Been Signed on 01/14/2025 12:55 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	GATEWAYS HOSPITAL AND MHC		FACILITY NUMBER:	198600612
ADMINISTRATOR/ DIRECTOR:	WILLIAM GOMEZ		FACILITY TYPE:	735
ADDRESS:	3455 PERCY STREET		TELEPHONE:	(323) 268-2100
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90023
CAPACITY: 136	TOTAL ENROLLED CHILDREN: 0	CENSUS: 92	DATE:	01/14/2025
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:55 AM
MET WITH:	Kirk Baker Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:10 PM

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Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced Case Management Visit to follow up on a Death Report received on 01/09/2025. LPA was met by Administrator Kirk Baker and explained the purpose of the visit.

Licensing received an email to report death of Client #1 (C1) on 01/09/2025. Client was found unresponsive by staff at 4:31 AM in client’s room on 01/09/2025 exact time of death is unknown. CPR was administered until paramedics arrived. Paramedics pronounced client deceased at 4:45 AM.

During today's visit LPA interviewed staff S1-S3, clients C2-C4 and obtained staff and client roster. LPA also toured C1's bedroom. No concerns, obstructions, or anything out of the ordinary was witnessed during the visit. Administrator had provided via email C1’s Physician’s report, face sheet appraisal/needs and service plan, and Medication Administration Record (MAR). LPA will also request facility to obtain and provide Licensing with C1's Death Certificate and police report upon receipt.

No deficiencies observed during today's visit. Exit interview held and a copy of the report was provided to the facility. LPA will continue to gather information about this incident.

Tony Vasallo	TELEPHONE: (323) 981-3977
Christian Gutierrez	TELEPHONE: 323-981-3984
	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

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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