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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601656
Report Date: 03/15/2024
Date Signed: 03/15/2024 09:48:26 AM

Document Has Been Signed on 03/15/2024 09:48 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:EASTER SEALS SOUTHERN CALIFORNIA EASTLYN RESIDENCEFACILITY NUMBER:
198601656
ADMINISTRATOR:JORGE ROMEROFACILITY TYPE:
735
ADDRESS:1299 EASTLYN PLTELEPHONE:
(626) 791-1597
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 4CENSUS: 3DATE:
03/15/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:41 AM
MET WITH:Saundra Sahagun AdministratorTIME COMPLETED:
10:06 AM
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Licensing Program Analyst (LPA) Sanjay Vaid initiated a case management visit to follow-up on the death of Client #1(C1). At 815 am Lyna White and Christina Gonzales were present at the facility, contracted adminstrator via phone. Adminstrator Saundra Sahagun arrived shortly after to conduct case management visit.

Facility completed death report for C1 dated 03/09/2024. C1 passed away at the facility on 03/08/2024. According to the report, after finishing dinner C1 stumbled twice while walking, staff helped C1 to his bedroom. C1 was conscious and breathing, staff helped C1 to his room where he collapsed. Staff called 911. Facility called paramedics around 5:45 PM. Paramedics arrived at the facility and pronounced the death at 6:00 PM, LA County Sheriff arrived shortly after to issue death report. The official cause of death is Cardiac Arrest.

LPA conducted a tour of the facility with administrator Saundra Sahagun. The tour included 4 client's bedrooms, 3 bathrooms, kitchen, dining room, living room, and common areas. LPA observed sharps,toxins and medications under lock and inaccessible to clients. There were no health and safety concerns at the time of the visit.

Administrator is working with C1's family to obtain the Death Certificate. Exit interview was held and a copy of the report was provided to the facility.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2024
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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