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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602037
Report Date: 10/20/2021
Date Signed: 10/20/2021 12:52:32 PM

Document Has Been Signed on 10/20/2021 12:52 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:MORENO FAMILY HOMEFACILITY NUMBER:
198602037
ADMINISTRATOR:BENNY MORENOFACILITY TYPE:
735
ADDRESS:14837 GALE AVE.TELEPHONE:
(626) 968-8420
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY: 6CENSUS: 5DATE:
10/20/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Benny Moreno -Administrator TIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Christine Wong conducted a Unannounced Case Management (Incident) visit to the facility in response to the Death Report of client (C1). Administrator Benny Moreno was explained the purpose of the visit. The purpose of today's visit is to check on the health & safety of the clients in care.

Client (C1) died on 10/18/2021 and it was reported that the administrator received a call from the day program and notified that C1 had a seizure and had fall in the restroom, other client called for staff assistance and performed chest compressions and called 911. Paramedics and Law Enforcement pronounced C1 death at the scene. The The death report was submitted in person to Community Care Licensing (CCL) on 10/19/2021.

During today's visit LPA interviewed another staff. Copies of the following documents were obtained:
Face Sheet
IPP
Recent Doctor visit report
Weight Record
Medication Administrative Record (MARs)

LPA requested the facility obtain a copy of the death certificate and submit it to CCL. A copy of the "Death Certificate" will be provided to CCL once received.

No Deficiency was observed during the visit

An exit interview was conducted. A copy of the report was provided to Administrator Benny Moreno.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2021
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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