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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601740
Report Date: 12/20/2022
Date Signed: 12/20/2022 01:19:09 PM

Document Has Been Signed on 12/20/2022 01:19 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:QUALITY OF LIFE ACADEMYFACILITY NUMBER:
198601740
ADMINISTRATOR:NNAEMEKA EZENAGUFACILITY TYPE:
775
ADDRESS:8439 CALIFORNIA AVENUETELEPHONE:
(562) 372-4750
CITY:SOUTH GATESTATE: CAZIP CODE:
90280
CAPACITY: 66CENSUS: 58DATE:
12/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:51 AM
MET WITH:Joshua Corzantes Program Director TIME COMPLETED:
01:35 PM
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 On 12/20/2022 at 11:51 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced case management inspection at the facility. LPA met with Joshua Corzantes to discuss the purpose of the visit, which is to gather additional information regarding the SIR/UIR (unusual incident report) dated 12/14//22 for an incident involving the death of client #1(C1).

According to the incident report, C1 was eating a morning snack (quesadilla) and began to show signs of choking. Staff performed back blows and performed CPR. The facility called the police and EMS client pronounced decease at 11:18 a.m.

During today's visit, LPA interviewed program director. LPA toured the facility and did not observe signs of neglect, abuse, or other immediate health and safety threats. LPA obtained copies of the following documents:

Report continued on 809C
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2022
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 2
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: QUALITY OF LIFE ACADEMY
FACILITY NUMBER: 198601740
VISIT DATE: 12/20/2022
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·Staff roster
· Resident roster
· Roster of staff present during the incident
· Roster of clients present during the incident
· C1 IPP
· Copy of incident report
· C1 medication list
· Identification and Emergency information
· Staff #1- Staff #5 CPR and first aid trainings.
· Coroner reference #2022-13016
· Police report reference # 22-118-27
· Food menu

Program Director is working on obtaining death certificate. Once facility obtains the death report, the facility will forward it to the Department for review

There were no citations given at this time. Exit interview was conducted and a hard copy of this report was provided to program director Joshua Corzantes.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022
LIC809 (FAS) - (06/04)
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