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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602156
Report Date: 10/22/2024
Date Signed: 10/22/2024 10:39:05 AM

Document Has Been Signed on 10/22/2024 10:39 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:DEL SOL HOME (CALIFORNIA)FACILITY NUMBER:
198602156
ADMINISTRATOR/
DIRECTOR:		GONZALES, HEINRICHFACILITY TYPE:
735
ADDRESS:17012 CALIFORNIA AVENUETELEPHONE:
(562) 804-4294
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: 3DATE:
10/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:41 AM
MET WITH:Crestine Dapedran - Caregiver/DSPTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced Case Management Visit to follow up on a Death Report faxed to the Department on 10/17/24. LPA met with Crestine Dapedran (Caregiver) and explained the reason for the visit.

Per Conversation with Melanie (caregiver), on 10/17/24 Client #1 (C1) was discovered as unresponsive as they were being prompted for wake up and shower, there was an attempt to retrieve vitals and staff were not able to get any readings, C1 was on hospice and hospice was called right away. The day prior C1 appeared to be their normal self, strong and ate well before bed, there was nothing unusual. Hospice confirmed time of death as 7:15am on 10/17/24.

On 10/17/24 (via email) LPA received the following copies from C1’s file : FACE Sheet, Death Report, Appraisal Needs & Services Plan, Physician's Report, and Medication Administration Record (MAR) for August - October 2024.

During today’s visit, LPA toured C1's bedroom which had already been cleared out by hospice and family. No concerns, obstructions, or anything out of the ordinary was witnessed during the visit. LPA has also requested facility to provide Licensing with C1's Death Certificate upon receipt.

No deficiencies observed during today's visit. Exit interview held and a copy of the report was provided to Crestine Dapedran (Caregiver).
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
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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