<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603034
Report Date: 05/11/2022
Date Signed: 05/11/2022 11:34:37 AM

Document Has Been Signed on 05/11/2022 11:34 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:WRIGHT PLACE BOARD AND CARE IIFACILITY NUMBER:
198603034
ADMINISTRATOR:BYERS, MAZERATTIFACILITY TYPE:
735
ADDRESS:4146 ARLINGTON AVENUETELEPHONE:
(323) 595-7917
CITY:LOS ANGELESSTATE: CAZIP CODE:
90008
CAPACITY: 4CENSUS: 3DATE:
05/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Malkia BennettTIME COMPLETED:
11:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 05/11/22, Licensing Program Analyst LPA/Gail Johnson and LPM/ Eva Alvarez conducted a Case Management visit to follow up on a death for Client #1 (C1). LPA and LPM met with Direct Service Professional Malkia Bennett who assisted with this visit. LPA Johnson explained the purpose of the visit was to gather information surrounding the death of (C1).

On 05/09/22, LPA Johnson received a call from Licensee Keisha Brown, who reported the death of (C1). Licensee Brown stated, (C1) passed away at the facility on 05/08/22. On 05/11/22, LPA Johnson and LPM Alvarez conducted a telephone interview with Administrator Mazeratti Byers to gain additional information regarding the passing of (C1) and toured the facility for any health and safety issues.

As of 05/11/22, LPA Johnson has obtained the following documents:

· Psychological Assessment,
· Identification and Emergency Information
· South Central Los Angeles Regional Center Triennial Individual Program Plan
· Record of Medications for 05/01/22 – 05/31/22
· Physician’s Report for Community Care Facilities 02/07/22
· Physician’s Order 04/27/21

Administrator was asked to provide copies of additional documents including a death certificate and test results when they become available.

LPA Johnson provided a copy of this report to Direct Service Professional Malkia Bennett. There were no citations during this visit.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Gail Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1