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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601766
Report Date: 07/06/2022
Date Signed: 07/07/2022 11:25:53 AM

Document Has Been Signed on 07/07/2022 11:25 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY 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: 92DATE:
07/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:11 PM
MET WITH:Dario EsguerraTIME COMPLETED:
04:59 PM
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On 07/06/22 Licensing Program Analyst, LPA Ernand Dabuet conducted a Case Management visit to follow up on the death reported for Client #1 (C1). LPA was greeted by Dario Esguerra and explained the purpose of the visit was to gather information surrounding the death of (C1).

The regional office received a copy of the death report from the facility and reported the death of (C1) on 07/01/22. The death report stated that approximately at 7:40 am on Thursday, 06/30/22 (C1) was found by staff #1 (S1) in her bathroom passed out and unconscious. The paramedics and Carson Sheriff arrived at the scene and performed CPR and declared (C1) deceased.

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)
  • Facility weekly Food Menu

An exit interview was conducted with Dario Esquerra and a hard copy was provided.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2022
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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