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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602966
Report Date: 08/22/2024
Date Signed: 08/22/2024 02:36:09 PM

Document Has Been Signed on 08/22/2024 02:36 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:CASTANA HOME CAREFACILITY NUMBER:
198602966
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, FLORANTEFACILITY TYPE:
735
ADDRESS:5629 CASTANA AVETELEPHONE:
(310) 418-0718
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY: 4CENSUS: 3DATE:
08/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:39 PM
MET WITH:Ruvy Pelesasa - House ManagerTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced case management visit to follow up on a death report faxed to the department on 08/16/24. LPA met with Ruvy Pelesasa (House Manager) and explained the reason for the visit.

During today's visit LPA Mora reviewed and obtained copies the following documents: Client 1 (C1) death report, physician's report, Individualized Program Plan, medication sheets for June 2024 - August 2024, Identification and Emergency Information sheet. LPA interview the House Manager, Staff 1 (S1), Client 2 (C2), and Client 3 (C3). Based on documents reviewed C1 was 56 years old, ambulatory, not able to care for all personal needs, needed assistance with activities of daily living (ADLs), and was conserved by a family member. Per medication sheets, C1 took all medication for the past 3 months as prescribed. C1 started having a cold and fever on 08/03/2024. The next day 08/04/2024 C1 appeared to be good, but just sleepy. On 08/05/2024, C1 got sick again and on 08/06/2024 morning C1 was a lot worse and did not appear to be getting better so the facility did a virtual urgent care, but they were instructed to take C1 to the emergency room. Facility call 911 and paramedics took C1 to the hospital on 08/06/2024. C1 was at the hospital from 08/06/2024 to 08/15/2024. She was diagnose with pneumonia and low oxygen levels. She was intubated. On 08/10/24, the tube was removed and C1 appeared to be well. On 08/12/24, the doctor determined that C1 needed to be re-intubated because C1 lungs kept getting a blockage. On 08/15/24, C1 appeared to be stable and they removed the tube, but C1's oxygen levels were low and had trouble breathing. It was decided to not re-intubate C1 anymore and C1 passed away on 08/15/2024 10:58pm.

No deficiencies were observed during this visit and LPA requested a copy of the death certificate to be forwarded to the department upon receiving it.

Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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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