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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600990
Report Date: 10/12/2023
Date Signed: 10/12/2023 10:19:54 AM

Document Has Been Signed on 10/12/2023 10:19 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:COUNTRY COTTAGE 1FACILITY NUMBER:
198600990
ADMINISTRATOR:POST, KIMFACILITY TYPE:
735
ADDRESS:14508 FONTHILL AVETELEPHONE:
(310) 973-7416
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY: 4CENSUS: 2DATE:
10/12/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Kim Post-AdministratorTIME COMPLETED:
10:19 AM
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On 10/12/23, Licensing Program Analyst, LPA Alfonso Iniguez conducted a Case Management visit to follow up on the death reported for Client #1 (C#1). LPA was greeted by administrator/ Kim Post who explained the purpose of the visit was to gather information surrounding the death of (C#1).

The Regional Office received a copy of the death report from the facility and reported the death of (C#1) on 10/7/23. The death report stated that (C#1) was admitted to Kindred Sub Acute on 09/08/23. (C#1’s) G tube was placed 10/5/23. Facility staff were able to sit with (C#1) daily 9am-11pm. According to facility staff on 10/07/23 (C#1) was doing well during his shift 8am - 8pm. By 11:35 pm he was unresponsive. According to the nurses at Kindred, they went in to do a blood sugar check and noted (C#1) had vomited and was unresponsive. A code was called, and resuscitation efforts failed

The following documents were requested:
· ID and Emergency Information
· Admission Agreement
· Physician Report for Community Care Facilities
· Pre-Appraisal Assessment.
· Medications (MAR)-3 months

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Kim Post/Administrator.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2023
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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