<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601448
Report Date: 04/29/2022
Date Signed: 04/29/2022 11:22:32 AM

Document Has Been Signed on 04/29/2022 11:22 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:A AND M III HOME CAREFACILITY NUMBER:
198601448
ADMINISTRATOR:ROBERTO RONASFACILITY TYPE:
735
ADDRESS:537 CONVERSE AVETELEPHONE:
(909) 618-7065
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 6CENSUS: 3DATE:
04/29/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Roxanne Arcibal TIME COMPLETED:
11:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Alma Gonzalez conducted a case management visit to follow-up on the death of Client 1 (C1). LPA met with Facility Coordinator Roxanne Arcibal and explained the reason for the visit. LPA interviewed Facility Coordinator Roxanne Arcibal and he stated that C1 had a surgery on 4/6/22 for Lipoma and was recuperating without any complications. According to the death report dated 4/23/22, C1 passed away on 4/23/22 at the facility. When staff attempted to wake C1 up client was unresponsive. Cause of death is unknown at the moment. C1;s health began declining since September 2021.

During today's visit, LPA reviewed documents that were submitted to Community Care Licensing Division (CCLD) via email and reviewed C1's file. LPA reviewed the following documents:

· San Gabriel/ Pomona Regional Center Placement Information
· Physician's Report/ PRN Authorization Letter/ Lab Results
· Medication Sheet dated for March 2022 -April 2022
· Appraisal/ Needs and Services Plan
  • Incident Reports
  • Individual Program Plan (IPP)
  • Hospital Records


Administrator and Facility Coordinator were asked to provide a copy of C1's death certificate when it becomes available.


Exit interview conducted and copy of Report was provided to Facility Coordinator Roxanne Arcibal.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1