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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602599
Report Date: 05/28/2024
Date Signed: 05/28/2024 02:58:00 PM

Document Has Been Signed on 05/28/2024 02:58 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:DEL SOL HOME (BEVERLY)FACILITY NUMBER:
198602599
ADMINISTRATOR/
DIRECTOR:		GONZALES, HEINRICHFACILITY TYPE:
735
ADDRESS:9914 BEVERLY STTELEPHONE:
(562) 243-4234
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: 3DATE:
05/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:54 PM
MET WITH:Heinrich Gonzales - AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced Case Management Visit to follow up on a Death Report faxed to the Department on 5/28/24. LPA met with Administrator Heinrich Gonzales and explained the reason for the visit.

The Department received a Special Incident Report dated 5/28/2024 indicating the following: On 5/27/24 at approximately 11:10am C1 was having lunch and suddenly started to spit out their food, they were observed having grimacing expressions and he lost consciousness, 911 was called immediately while other staff began to administer CPR, paramedics arrived and took over at approximately 11:20, however, C1 was pronounced deceased at 11:25 by the paramedics.

During today's visit LPA interviewed the Administrators Heinrich Gonzales and Merci Gonzales and (1) Caregiver, obtained copies of C1's FACE Sheet, Death Report, Appraisal Needs & Services Plan, Physician's Report, and Medication Administration Record (MAR) for March 2024-May 2024.

LPA also toured C1's bedroom. No concerns, obstructions, or anything out of the ordinary was witnessed LPA has requested facility to obtain and provide Licensing with C1's Death Certificate upon receipt.

No deficiencies observed during today's visit.

Exit interview held and a copy of the report was provided to Administrator Merci Gonzales.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2024
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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