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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601623
Report Date: 07/12/2022
Date Signed: 07/12/2022 03:51:28 PM

Document Has Been Signed on 07/12/2022 03:51 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:PATE ENTERPRISES, INC. ( MENLO )FACILITY NUMBER:
198601623
ADMINISTRATOR:WESLEY PATE, JR.FACILITY TYPE:
735
ADDRESS:14801 GRAMERCY PLACETELEPHONE:
(213) 725-4634
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY: 6CENSUS: 5DATE:
07/12/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Renita CampbellTIME COMPLETED:
04:00 PM
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
On 07/12/22, Licensing Program Analyst (LPA) Gail Johnson and (LPA) Stephanie Cifuentes conducted a Case Management visit to follow up on the death for Client #1 (C1). LPA Johnson and Cifuentes were greeted by staff Mabel Walker. LPA Johnson explained the purpose of the visit was to gather information surrounding the death of (C1).

On 07/08/22, LPA Johnson documented the death of (C1) and called Assistant Administrator Renita Campbell. Assistant Administrator Campbell stated, (C1) passed away at the facility on 07/03/22. On 07/12/22, LPA Johnson and Cifuentes toured the facility, interviewed Assistant Administrator Renita Campbell, Staff (S1)-S2, and (C2) – (C6).

On 07/12/22, LPA Johnson requested the following documents:
· Identification and Emergency Information
· Individual Program Plan (IPP) & Individualized Behavior Support Plan (IBSP)
· Medication Administration Record (MAR)
· Most Recent Physician’s Report / Assessment
· Death Certificate (When available)

Based on the facility tour, the licensee violated the California Code Regulations (CCR) of Title 22 sections 80087 Division 6 Chapter 1. On 07/12/22, LPA Johnson and Cifuentes observed several broken pieces of the living room tile floor, items that need to be thrown away in the backyard and the client bathroom needed to be cleaned.

Plan of Correction


Assistant Administrator Campbell stated that the facility will have the bathroom and backyard cleaned and tile floor repaired by 08/01/22. Report Continued on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Gail Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2022
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PATE ENTERPRISES, INC. ( MENLO )
FACILITY NUMBER: 198601623
VISIT DATE: 07/12/2022
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
26
27
28
29
30
31
32
Continued from 809


LPA Johnson provided a copy of this report to Assistant Administrator Renita Campbell.

End of Report
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Gail Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 07/12/2022 03:51 PM - It Cannot Be Edited


Created By: Gail Johnson On 07/12/2022 at 01:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PATE ENTERPRISES, INC. ( MENLO )
FACILITY NUMBER: 198601623

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2022
Section Cited
CCR
80087(a)

1
2
3
4
5
6
7

80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not as evidenced by:
1
2
3
4
5
6
7
Licensee stated that the facility will have the bathroom and backyard cleaned and tile floor repaired by 08/01/22. This citation must be corrected immediately by POC 08/01/2022.
8
9
10
11
12
13
14
On 07/12/22, LPA Johnson and Cifuentes observed several broken pieces of the living tile room floor, items that need to be thrown away in the backyard and the client bathroom needed to be cleaned.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva M Alvarez
LICENSING EVALUATOR NAME:Gail Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3