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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602883
Report Date: 03/22/2023
Date Signed: 03/22/2023 11:09:43 AM

Document Has Been Signed on 03/22/2023 11:09 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SANDRA'S HOUSE LLC #3FACILITY NUMBER:
198602883
ADMINISTRATOR:BENSON, SANDRAFACILITY TYPE:
735
ADDRESS:1908 STEVELY AVETELEPHONE:
(562) 843-8522
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY: 4CENSUS: 4DATE:
03/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:31 AM
MET WITH:Sandra Benson, AdministratorTIME COMPLETED:
11:17 AM
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On 3/22/23 Licensing Program Analyst (LPA) Mario Leon conducted an unannounced Case Management inspection. LPA met with Sandra Benson, Administrator to discuss the purpose of todays visit which involves gathering additional details surrounding the death of Client #1 which occurred on February 28, 2023.

During the visit LPA reviewed Client #1's file and requested copies of supportive documents (Physician's order, most current Physicians report, most current Nurse's notes). The facility has provided CCLD with the necessary documents requested, and has completed a Death report and SIR within the required time frame.

The Facility currently does not have a copy of the police/fire department report. A copy of the police/fire department report will be forwarded as soon as the Administrator Sandra Benson receives it on 3/27/2023.

Investigation:
LPA interviewed Licensee/Administrator Sandra Benson and S1, client #1 was coming from Dungarvin, Signal Hill Adult Day Program back to the facility. Showing no vitals.

The licensee/Administrator shall submit a copy of the Death Certificate and Police report and LB fire report to LPA Leon upon receipt.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2023
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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