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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601493
Report Date: 08/23/2021
Date Signed: 08/23/2021 11:15:57 AM

Document Has Been Signed on 08/23/2021 11:15 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:GMS ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198601493
ADMINISTRATOR:CHRISTOPHER SORTOFACILITY TYPE:
735
ADDRESS:18322 SUBIDO STREETTELEPHONE:
(626) 820-9387
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 6CENSUS: 4DATE:
08/23/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sonia Mendez (DSP)TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Kruz Long conducted a Case Management visit to follow-up on the death of Client #1. LPA met with Sonia Mendez (DSP) who assisted with the visit. LPA explained the purpose of the today's visit.

During today's visit, LPA interviewed Staff #1 who stated that Client #1 went to the hospital because Client #1 felt sick and threw up. Night staff called 911 and ambulance took Client #1 to the hospital. Client #1 later passed away in the hospital. Hospital indicated that Client #1 passed away due to Covid-19.

Copies of the following documents were obtained during Case Management visit:

-Facesheet
-Identification
-Blood sugar record
-Medical/Specialist Visit information
-Physical Exam
-MAR
-Covid-19 Vaccination Card

LPA advised facility to fax a copy of the following documents:
-Individual Program Plan
-Death Certificate

Administrator was informed to provide a copy of the death certificate once available. Until cause of death is confirmed investigation will continue.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2021
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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