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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602601
Report Date: 12/16/2021
Date Signed: 12/16/2021 04:24:37 PM

Document Has Been Signed on 12/16/2021 04:24 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:DEL SOL HOME (BEACH)FACILITY NUMBER:
198602601
ADMINISTRATOR:GONZALES, MERCI CANIAFACILITY TYPE:
735
ADDRESS:10248 BEACH STTELEPHONE:
(562) 243-4234
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: 4DATE:
12/16/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Merci GonzalesTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Alma Gonzalez conducted a Case Management visit for the death of Client 1 (C1) which occurred on 7/31/21.

LPA made an initial visit on 8/5/21. LPA received death certificate for C1 on 11/17/21. LPA
reviewed the death certificate. The death certificate indicates that the immediate cause of death for C1 was Acute Respiratory Failure, Septic Shock, and Diabetes Mellitus Type II. Place of Death: St. Francis Medical Center.

Based on the available information reviewed, LPA did not note any deficiencies in reference to C1's death.

Exit interview conducted and copy of report was provided to Administrator Merci Gonzales.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2021
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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