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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602627
Report Date: 10/02/2024
Date Signed: 10/03/2024 08:02:54 AM

Document Has Been Signed on 10/03/2024 08:02 AM - 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:CALIFORNIA MENTOR - 230TH STREET HOMEFACILITY NUMBER:
198602627
ADMINISTRATOR/
DIRECTOR:		ROSAS, CLAUDIOFACILITY TYPE:
735
ADDRESS:434 W 230TH STREETTELEPHONE:
(909) 483-2505
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 3CENSUS: 2DATE:
10/02/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:06 PM
MET WITH:Nickie Southall TIME VISIT/
INSPECTION COMPLETED:
02:27 PM
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On 10/02/23, Licensing Program Analyst, LPA Ernand Dabuet conducted a Case Management visit to follow up on the death reported for Client #1 (C1). LPA was greeted by Program Manager Nickie Southall. LPA explained the purpose of the visit was to gather information surrounding the death of (C1).

LPA Dabuet received an email from Southall on 09/27/24 who reported the death of (C1) on 09/27/24 and later submitted an incident report LIC 624. The death report stated that (CI) passed away on 09/27/24 at 8:00 am at Harbor UCLA Medical Center (HUCLAMC). According to the incident report (C1) was admitted on 09/25/24 was recommended by Harbor Regional Center physician as (C1) was unable to urinate within the 24-hour period. Emergency Medical Services were dispatched on 09/25/24, (C1) while being observed at the hospital was taken off prescribed meds and was administered morphine and was placed on comfort care while at the hospital. (C1) while under hospital care when (C1) passed away.

The following documents were requested:
  • ID and Emergency Information (dated: 04/21/23)
  • Admission Agreement (dated: 06/15/2019)
  • Physician Report for Community Care Facilities LIC 602A (dated: 03/16/23)
  • Quarterly Nursing Assessment (dated: 09/25/24)
  • Medications (MAR) (dated: 09/01/24 - 09/26/24)
  • Incident Report LIC 624 (dated: 08/08/24)
  • Progress Notes (dated: 09/09/24 - 09/27/24)
  • Discharge Checklist (dated: 09/27/24)
  • Vital Signs Record (dated: 09/07/24 - 09/25/24)
  • Hydration Chart (dated: 09/01/24 - 09/26/24)
  • BM Function Form (date: September 2024)
  • Body/Skin Check Form (date: 09/03/24-09/24/24)

A brief interview was conducted with Nickie Southall regarding (C1's) health condition,and a hard copy of the report is provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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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