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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601766
Report Date: 11/02/2021
Date Signed: 11/04/2021 01:02:00 PM

Document Has Been Signed on 11/04/2021 01:02 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
MONTERY PARK, CA 91754
FACILITY NAME:OLIVIA ISABEL MANORFACILITY NUMBER:
198601766
ADMINISTRATOR:KUNZ, ANAFACILITY TYPE:
735
ADDRESS:21515 S. FIGUEROA STREETTELEPHONE:
(310) 328-5116
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 110CENSUS: 91DATE:
11/02/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:ANA KUNZTIME COMPLETED:
11:48 AM
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On 11/02/21 Licensing Program Analyst, LPA Ernand Dabuet conducted a Case Management visit to follow up on death reported for Client #1 (C1). LPA was greeted by the administrator Ana Kunz and explained the purpose of the visit was to gather information surrounding the death of (C1).

On duty desk received a copy of the death report from the facility and reported the death of (C1) on 10/26/21. The death report stated that approximately at 10:15 pm on Friday, 10/22/21 a family member called to inform management that (C1) had passed at Harbor UCLA Medical Center due to multiple injuries from an accident. According to management, (C1) was last seen on Thursday, 10/14/21 at 8:30 am leaving the facility. Carson Sheriff was dispatched and a missing person report #021-09959-1617-400 was taken on 10/15/21.

The following documents were requested:
· ID and Emergency Information,
· Admission Agreement
· Physical Health Intake Assessment,
· Physician Report for Community Care Facilities,
· Pre-Admission Assessment.
Medications (MAR)

LPA conducted an interview with staff #1 (S1) and witness #1(W1). Resident #2 (R2) was not at the facility for an interview.

An exit interview was conducted with Ana Kunz and a hard copy was provided via email for signature.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2021
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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