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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601253
Report Date: 04/09/2024
Date Signed: 04/10/2024 10:41:07 AM


Document Has Been Signed on 04/10/2024 10:41 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:EASTER SEALS SOUTHERN CALIFORNIA HAYFORD HOMEFACILITY NUMBER:
198601253
ADMINISTRATOR:NJOROGE, PRISCILLAHFACILITY TYPE:
735
ADDRESS:11502 HAYFORD STTELEPHONE:
(562) 484-9153
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:4CENSUS: 3DATE:
04/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:18 PM
MET WITH:Armando FloresTIME COMPLETED:
04:45 PM
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 Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced visit to investigate the death of client C1. Community Care Licensing Division received a death report at an ARF which led to this investigation.

The client was not in the facility at the time of death. LPA Wesley collected the Face sheet, IPP, Mar log, Physician's report, SIR during the visit. On 03/29/24 at 9am, staffed called 911 because the clients oxygen levels were between 84-86. Client was transported to Coast Plaza Hospital. The MD stated he possible has pnuemonia. They put them on oxygen and gave them an antibiotic though IV. On 04/05/24 the hospital called and said the client was ready to come back, but they had a IV, and the facility couldn't accept the client back due to the IV, so the Hospital transferred the client to a SNF- Elena Villa Health Care on Friday, April 05, 2024. On Monday, 04/08/24 staff at Elena Villa Health Care called 911 at 7:20 am, and the client was transferred to PIH in whiitier. The client passed.

The cause of death is unknown. The licensee was informed when he gets the Death Certificate, to forward a copy to Community Care Licensing Division(CCLD).
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
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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