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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602383
Report Date: 11/18/2022
Date Signed: 11/18/2022 09:40:56 AM

Document Has Been Signed on 11/18/2022 09:40 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:RACHEL'S QUALITY HOMEFACILITY NUMBER:
198602383
ADMINISTRATOR:SABILLO, VENERANDA OFACILITY TYPE:
735
ADDRESS:18202 GALATINA STREETTELEPHONE:
(626) 295-2976
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 4CENSUS: 2DATE:
11/18/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Vennie O Sabillo TIME COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced Case management Visit to follow up on a Death Report faxed to the Department on 11/07/2022. LPA was met by DSP Roselyn Ochoada and explained the reason for the visit. Shortly after, administrator Vennie O Sabillo arrived and assisted with the visit.

On 11/05/22, Client#1 (C1) was sent to hospital due to C1 threw up and was feeling nauseated. On 11/06/22, the administrator called the hospital to follow up C1's health condition and reported C1 was admitted to ICU due to decreasing oxygen saturation level. On 11/07/22, administrator received a call from the hospital and stated that C1 passed away at 7:27am.

During today's visit, LPA was provided with the following documents of C1:
  • Placement information /Face Sheet
  • Functional Capability Assessment
  • Client Notes
  • Lab result dated on 01/08/2019
  • physical exam dated on 09/28/22
  • Individual Program Plan (IPP)
  • Medication administration Sheet for Oct and Nov 2022.
  • C1 has no family members and San Gabriel Pomona Regional Center was contacted on 11/07/22
  • Cause of death was unknown at this time

LPA advised Administrator to send a copy of the death certificate to Licensing when it becomes available.
No deficiencies were cited per California Code of Regulations, Title 22, Division 6 during this visit.
Exit Interview conducted and a copy of the report was provided to the administrator.




SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
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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