<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602255
Report Date: 04/11/2022
Date Signed: 04/12/2022 06:49:09 AM

Document Has Been Signed on 04/12/2022 06:49 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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:CALIFORNIA MENTOR - DOMINGUEZ HOMEFACILITY NUMBER:
198602255
ADMINISTRATOR:ROSAS, CLAUDIOFACILITY TYPE:
735
ADDRESS:214 E DOMINGUEZTELEPHONE:
(909) 483-2505
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 3CENSUS: 2DATE:
04/11/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:13 PM
MET WITH:Claudio RosasTIME COMPLETED:
02:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 04/11/22 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 the Program Director Claudio Rosas. LPA explained the purpose of the visit was to gather information surrounding the death of (C1).

On duty desk received a copy of the death report from the facility and reported the death of (C1) on 04/07/22. The death report stated on 03/31/22 Harbor Regional Center Service Coordinator Cady Laycook notified Rosas that (C1) had passed at Coast Plaza Hospital, for unknown reasons. According to Rosas, (C1) was admitted to Harbor UCLA for a fall that took place on 12/20/21 for a head injury. (C1) was taken to Beachside Post Acute on 01/05/22. While at Beachside (C1) suffered another fall and G-Tube infection and was taken to back Harbor UCLA. On 02/03/22 (C1) was admitted to InterCommunity Care Center and was at this nursing home until 03/25/22. (C1) was sent to Coast Plaza Hospital for oxygen saturation and experienced weakness and passed away 03/31/22.

The following documents were requested:
  • Client Individual Face Sheet
  • Admission Agreement
  • Functional Capability Assessment
  • Physician Report for Community Care Facilities
  • PrePlacement Assessment
  • Appraisal/Needs and Service Plan
  • Client's IPP
  • Client's CDER Profile
  • Quarterly Assessment
  • Medications (MAR)
LPA conducted an interview with staff #1.
An exit interview was conducted with Claudio Rosas and a copy of report was provided.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2022
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 1