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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601069
Report Date: 09/07/2023
Date Signed: 09/07/2023 03:26:46 PM

Document Has Been Signed on 09/07/2023 03:26 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:BONNIE'S GUEST HOUSE INC.FACILITY NUMBER:
198601069
ADMINISTRATOR:ALVARADO, DESIREEFACILITY TYPE:
735
ADDRESS:135 NORTH BONNIE AVENUETELEPHONE:
(626) 440-0494
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY: 14CENSUS: 13DATE:
09/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Marlene Urquilla - StaffTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit to follow up on death report faxed to the department on 9/6/23. LPA met with Marlene Urquilla and explained the reason for the visit.

During today's visit LPA Flores reviewed the following documents; death report faxed to the department on 9/6/23. LPA reviewed and obtain copies of physician's report dated: 3/20/23, admission agreement dated: 3/20/23, needs and service plan dated: 3/20/23, medication sheets for August-September 2023, Identification and Emergency Information sheet dated: 3/20/23. LPA interview C1's roommate (C3), and client #2(C2).

Based on documents reviewed C1 was not conserved, ambulatory, and able to take care of self. Per medication sheets C1 took his medication for the past two months. On 9/3/23 Staff #1(S1) checked on C1 at 10:10pm and noticed C1 was sleeping in his bed. At 11:00pm client #2(C2) found C1 in the bathroom floor unconscious and notify S1. S1 contacted 911, police and paramedics arrived. Paramedics attempted to resuscitate C1 and pronounce C1 death at 11:48pm.Police department provided facility with case #PA2023-73531. Police contacted the responsible party notify the death and of need to make arranges for a mortuary to take care of funeral arrangements as the cause of death was due to natural causes. Mortuary services picked up the body. Administrator provided C1's belongings to family on 9/5/23.

No deficiencies were observed during this visit and LPA requested Administrator to forward death certificate to the department upon receiving it.


Exit interview was conducted with Marlene Urquilla and a copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2023
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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