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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601530
Report Date: 07/09/2024
Date Signed: 07/09/2024 02:24:22 PM

Document Has Been Signed on 07/09/2024 02:24 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:EASTER SEALS SOUTHERN CALIFORNIA PROSPERO HOMEFACILITY NUMBER:
198601530
ADMINISTRATOR/
DIRECTOR:		SAMUEL BENEDICT B CABARONFACILITY TYPE:
735
ADDRESS:1046 N PROSPERO DRTELEPHONE:
(626) 339-1482
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 4CENSUS: 3DATE:
07/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Samuel Cabaron, administratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced case management visit regarding the death of client #1 (C1) which occurred on 06/30/24. LPA met with administrator, Samuel Cabaron, and explained the reason of the visit. Per the incident report dated 06/30/24, C1 deceased on 06/30/24 who was found unresponsive in client’s bed in the facility at around 5:45am. The suspected cause of death was cardiac arrest.

During today's visit, Samuel Cabaron was interviewed, C1's files were obtained as the following:
· Staff roster and Client roster
· Client #1 (C1) facesheet / Identification and Emergency information
· Unusual incident report/ Death report, dated 06/30/24
· Physician report, dated 05/23/24
· C1's IPP, dated 01/17/24
· C1's Medication record, May and June 2024
· C1’s Record of health care visit, dated 06/19/24
· C1's SNF discharge report, dated 05/03/24
· C1's ER discharge report, dated 05/22/24
· C1’s Death Certificate worksheet, dated 07/02/24.

Samuel stated the death certificate worksheet, dated 07/02/24, was signed by signed by Dr. Jung Chiong. The causes of death were cardiac arrest and hypertension.

No deficiencies were observed and cited during this visit. Exit interview was conducted and a copy of LIC 809 Report was provided to Samuel.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2024
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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