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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602542
Report Date: 01/18/2024
Date Signed: 01/18/2024 03:38:08 PM

Document Has Been Signed on 01/18/2024 03:38 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:CHELSEA RESIDENTIAL CAREFACILITY NUMBER:
198602542
ADMINISTRATOR:HARRISON, HONORAFACILITY TYPE:
735
ADDRESS:2030 W 144 STREETTELEPHONE:
(310) 515-4757
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY: 4CENSUS: 2DATE:
01/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:26 PM
MET WITH:Zoie ClarkTIME COMPLETED:
03:40 PM
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On 01/18/24 Licensing Program Analyst (LPA) Felisa Shirley conducted a Case Management visit to follow up on the death reported for Client #1 (C1). LPA was greeted by Zoie Clark. LPA spoke with Zoie and explained the purpose of the visit was to gather information surrounding the death of (C1).

The regional office received a copy of the death report from the facility who reported the death of (C1) on 12/19/23 at 9pm. The death report stated that approximately 9:00pm on 12/19/23 (C1) was found by staff #2 (S2) in her room on the bed. Client asked staff for water. When staff returned to give water to client, client screamed and her eyes rolled back. Paramedics were dispatched, paramedics arrived and performed CPR on client for cardiac arrest but client (C1) passed away.

The following documents were requested:

· ID and Emergency Information,
· Admission Agreement
· Physician Report for Community Care Facilities
· Functional Capability Assessment
· Consents/Certifications for Placement
· Annual Physical
· Medications (MAR)

No deficiencies were cited during this visit.

An exit interview was conducted with Zoie Clark and a hard copy was provided.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
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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