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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601376
Report Date: 07/28/2022
Date Signed: 07/28/2022 04:30:34 PM

Document Has Been Signed on 07/28/2022 04:30 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ARRIOLA FAMILY HOMEFACILITY NUMBER:
198601376
ADMINISTRATOR:LORENZO ARRIOLAFACILITY TYPE:
735
ADDRESS:1307 S. EVARG AVETELEPHONE:
(310) 537-3925
CITY:COMPTONSTATE: CAZIP CODE:
90220
CAPACITY: 6CENSUS: 5DATE:
07/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Lorenzo ArriolaTIME COMPLETED:
03:45 PM
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On 07/28/22 Licensing Program Analysts, (LPAs) Ernand Dabuet and Perry Scott conducted a Case Management visit to follow up on the death reported for Client #1 (C1). LPA was greeted by Lorenzo Arriola and explained the purpose of the visit was to gather information surrounding the death of (C1).

The regional office received a copy of the death report from the facility and reported the death of (C1) on 07/20/22. The death report stated that approximately at midnight on Tuesday, 07/19/22. According to the administrator, the (C1) was taken to Lakewood Memorial Emergency on 06/14/22 at 10 am due to stomach bloating and hiccups medical condition. Ct scan, x-rays, and blood test were performed and found that air was trapped in his diaphragm. (C1) was later transferred to LA Community Hospital and was admitted. The cause of death is unknown and under investigation.

The following documents were requested:
  • ID and Emergency Information,
  • Physical Health Assessment
  • Medical Examination Form
  • Medications (MAR)


The facility is not the conservator or the power of attorney and was not able to obtain medical records from LA Community Hospital. CCLD will reach out to South Central Regional Center coordinator Kemmi Hudson for supporting documents.

An exit interview was conducted with Lorenzo Arriola and a hard copy was provided.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2022
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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