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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602392
Report Date: 07/23/2024
Date Signed: 07/23/2024 02:30:36 PM

Document Has Been Signed on 07/23/2024 02:30 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CHOICES R US - STOAKESFACILITY NUMBER:
198602392
ADMINISTRATOR/
DIRECTOR:
MARC SWEETFACILITY TYPE:
735
ADDRESS:9022 STOAKES AVETELEPHONE:
(562) 445-3009
CITY:DOWNEYSTATE: CAZIP CODE:
90240
CAPACITY: 4CENSUS: 3DATE:
07/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:John Paul Adeleye (Administrator)TIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced case management visit to follow up on a death report faxed to the department on 07/17/24. LPA met with John Paul Adeleye (Administrator) and explained the reason for the visit.

During today's visit LPA Mora reviewed the following documents: death report faxed to the department on 07/17/24. LPA reviewed and obtain copies of physician's report dated: 04/07/23, Individualized Program Plan dated 04/24/23, medication sheets for June and July 2024, Identification and Emergency Information sheet dated: 10/11/18. LPA interview administrator, Staff 5 (S5), Staff 6 (S6), and attempted to reach Regional Center Service Coordinator.

Based on documents reviewed C1 was not conserved, ambulatory, and able to care for all personal needs. Per medication sheets C1 took all medication for the past two months. On 07/15/24, C1 attended day program and returned nothing unusual was noted. C1 took all the medication and went to bed. At 2:00 AM, S1 saw C1 go to the bathroom. At 5:45 AM, C1 was still asleep. Between 6 - 6:30 AM, C1 is awakened by S4 to go to day program. S4 noticed C1 was still sleepy, and S4 decided to give C1 time to continue sleeping. At 7:15 AM, S4 observed the client and client looked lethargic. C1 was kept home and it was decided C1 would not attend day program. At 8:30 AM, the administrator was notified that C1 threw up. Staff were directed to give the client liquids. At 9:12 AM, Supervisor Gilbert Cardenas went to the facility to observe C1. He instructed staff to give C1 fluids/gatorade. At 9:30 AM, while staff were getting the client ready to go to the hospital, the client began having shortness of breath. Staff immediately called 911. Client was transported via ambulance to the hospital. Administrator stated that on 07/16/24 in the afternoon regional center service coordinator called him to let him know that C1 passed away at the hospital. On the morning of 07/17/24, the administrator's supervisor called the hospital to get more information of what happened, but they told him that they could not released any information to them and they could only say that it was a possible respiratory failure and septic shock. The hospital communicated directly with regional center. Administrator stated that regional center will have more specific details and possibly the death certificate.

No deficiencies were observed during this visit and LPA requested administrator to forward death certificate to the department upon receiving it. Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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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