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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601766
Report Date: 05/22/2023
Date Signed: 05/23/2023 08:46:24 AM

Document Has Been Signed on 05/23/2023 08:46 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: 85DATE:
05/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:26 AM
MET WITH:Ana Kunz TIME COMPLETED:
10:59 AM
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On 05/22/23, 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 administrator Ana Kunz who 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 05/18/23. The death report stated that (CI) passed away on 05/17/23 at around 12:05 pm in Harbor UCLA Medical Center. According to the incident report (C1) was having lunch in the dining room. When (C1) completed the meal and stood up (C1) felt ill and sat back down. Care staff noticed (C1) leaning over the table and went over to check on (C1). (C1) appeared that he had a seizure. The care staff dispatched emergency medical services (EMS). Care staff started to administer CPR until (EMS) arrived and transported (C1) to the hospital. (C1) while under hospital care passed away at the hospital. The facility notified the family representative.

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)

An exit interview was conducted with Ana Kunz and a hard copy was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2023
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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