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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602556
Report Date: 02/25/2025
Date Signed: 02/25/2025 01:42:39 PM

Document Has Been Signed on 02/25/2025 01:42 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PDM-HORSTFACILITY NUMBER:
198602556
ADMINISTRATOR/
DIRECTOR:
LOPEZ, ARCHIMEDES CFACILITY TYPE:
735
ADDRESS:18318 HORST AVETELEPHONE:
(562) 552-5579
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY: 4CENSUS: 1DATE:
02/25/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Hazzelle Puason-CaregiverTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) S Vaid conducted a case management visit for the death of Client #1 (C-1). LPA met with caregiver Hazzelle Puason, Administrator- Archimedes Lopez was informed and arrived shortly after, and explained the purpose of the visit. Licensee Mary Gonzales also arrived to facility for assistance.

The facility submitted a death report for C-1 who passed away on 02/18/2025 at the hospital. According to the death report and interview with the Administrator, C1 had chronic pulmonary condition. Service coordinator at Harbor Regional was aware of this ongoing sickness. C1 was non-verbal, deafness and blindness. C1 was able to communicate by hand gestures.

On 02/10/25 C1, was transported by paramedics and admitted to La Palma Inter-community Hospital for COPD exacerbation and pneumonia. While at the hospital C1 experienced seizure like activity on 02/17/25, C1 was further admitted to ICU where C1 reportedly had cardiac arrest. C1 was resuscitated but required maximum oxygen, heart medication. C1 had multi-organ failure and passed away on 02/18/25. Facility notified Harbor Regional and Licensing on 02/19/25.

LPA obtained copies of the following documents: Face sheet, Physician's Report, MAR log for January and February 2025, and IPP Regional Center annual report dated 06/24/2024.

LPA also requested for a copy of the death certificate when it becomes available.

An exit interview was conducted, and a copy of this report was provided to the Licensee, Mary Gonzales.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
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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