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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601864
Report Date: 03/20/2023
Date Signed: 03/20/2023 10:59:13 AM

Document Has Been Signed on 03/20/2023 10:59 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
CCLD Regional Office,
, CA
FACILITY NAME:DUNGARVIN CALIFORNIA - LONG BEACHFACILITY NUMBER:
198601864
ADMINISTRATOR:GORDON DAMEONFACILITY TYPE:
775
ADDRESS:2534 E SOUTH STTELEPHONE:
(562) 408-4801
CITY:LONG BEACHSTATE: CAZIP CODE:
90805
CAPACITY: 30CENSUS: 11DATE:
03/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Rian Phillips, Program DirectorTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent case management visit regarding the death of Client #1. LPA met with Program Director, Rian Phillips, and the purpose of the visit was explained.

On 11/18/2019, LPA Chan conducted a health and safety check at the facility site and gathered documents pertaining to Client #1 (C-1). This visit was initiated due to C-1 passing away on 6/18/2019 as a result of choking. Due to nature of this death, the Department of Social Services Investigation Bureau (IB) Investigator Jose Santana conducted a further investigation. Investigator Santana interviewed the previous Program Director, Dameon Gordan, Staff, and Clients who were present during this incident.

The incident occurred on 6/18/2019 at Cherry Park in Long Beach, where a group of 5 clients and 2 staff stopped to eat their snacks/lunches. While staff #1 (S-1) was preparing their snacks, C-1 grabbed some chicken nuggets from a container and shoved it in his/her mouth. S-1 quickly intervened and tried to remove the food from client’s mouth using 2 fingers. S-1 told Staff #2 to perform the Heimlich maneuver, but nothing came out. C-1 walked away towards the van and Staff assumed C-1 was no longer in distress. Staff directed the clients to get back in the van so they could return to the facility. Staff noticed C-1 was seen turning blue and immediately dialed 911. S-1 followed the operator’s CPR instructions until the paramedics arrived and took over. C-1 was pronounced deceased at the scene on 6/18/2019.

The investigation revealed that C-1 required close monitoring due to the tendency of grabbing other people’s food and placing it in his/her mouth. Staff interviewed indicated that the Program Director did not inform them that C-1 required special meal preparation. Staff learned of C-1’s behavior through observations and from other Direct Services Professional (DSP) staff. The former program director failed to adequately notify DSPs about C-1’s chopped diet requirement, as specified in the Individual Program Plan. In addition, the program director did not ensure that S-1’s CPR/First Aid certification, which expired on 5/2/2019, was current at the time of incident.

Based on documentation and interviews conducted, it is determined the client choked on food and died while in care as a result of the facility’s negligence. An Immediate Civil Penalty of $500 is being issued today. Refer to LIC421IM. The issuance of an additional Civil Penalty is being assessed based on health and safety code 1548 (2)(A), if the department determines the death of the client is due to neglect.


An exit interview was held. A copy of this report, LIC421IM, and appeal rights were given to Ms. Phillips.

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2023
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
Document Has Been Signed on 03/20/2023 10:59 AM - It Cannot Be Edited


Created By: Cynthia D Chan On 03/20/2023 at 10:42 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA

FACILITY NAME: DUNGARVIN CALIFORNIA - LONG BEACH
FACILITY NUMBER: 198601864

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/21/2023
Section Cited
CCR
82078(a)

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82078 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision necessary to meet the client's needs and all services specified in the admission agreement.
This requirement is not met as evidenced by:
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Licensee shall provide proper training and updates as needed to ensure that all staff are competent to provide the services necessary to meet individual client needs. The proof of training shall be submitted to LPA by POC due date 3/21/23.
***A civil penalty of $500 is being issued.****
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Based on interviews and record review, the program director did not provide proper training to staff regarding C-1’s behaviors and special diet requirement which posed as an immediate health and safety risks to clients in care.
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Type A
03/21/2023
Section Cited
CCR82075(f)

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82075 Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive and maintain current training in first aid and cardiopulmonary resuscitation....This requirement is not met as evidenced by:
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Licensee shall ensure all staff are current in their CPR/First Aid certification. A list of employees and their certifications shall be submitted to LPA by POC due date 3/21/23.

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Based on document reviewed, Staff did not have current CPR & First Aid certification which posed an immediate health and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Christine Yee
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2