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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601253
Report Date: 07/15/2024
Date Signed: 07/15/2024 11:35:26 AM

Document Has Been Signed on 07/15/2024 11:35 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:EASTER SEALS SOUTHERN CALIFORNIA HAYFORD HOMEFACILITY NUMBER:
198601253
ADMINISTRATOR/
DIRECTOR:		NJOROGE, PRISCILLAHFACILITY TYPE:
735
ADDRESS:11502 HAYFORD STTELEPHONE:
(562) 484-9153
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 2DATE:
07/15/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Kimya OliverTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Alma Gonzalez conducted a case management visit to follow-up on the death of Client 1 (C1). LPA met with Director Kimya Oliver and explained the reason for the visit. According to the death report dated 07/08/24, C1 passed away on 07/07/24. Immediate cause of death noted on LIC 624A Death Report is noted as Hypoxia and Cardiac Arrest. Conditions contributing to death are noted as C1 was hospitalized on 06/16/24 due to low oxygen levels and was intubated twice/ pending tracheostomy.

The facility provided the following documents prior to the visit:
  • Death Report LIC 624A
  • Unusual Incident/ Injury Report dated 07/08/24
  • C1 Face Sheet
  • Physician's Report for Community Care Facilities LIC 602
  • Copy of C1's medication record for month of June 2024

During today's visit, LPA reviewed C1's facility file and interviewed Director Kimya Oliver and copies of the following documents were provided:
  • Preplacement Appraisal Information LIC 603
  • Copy of C1's medication record for month of May 2024


Director Kimya Oliver was asked to provide a copy of the death certificate when it becomes available.


Exit interview conducted and copy of Report was provided to Director Kimya Oliver.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2024
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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