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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603045
Report Date: 09/10/2021
Date Signed: 09/10/2021 01:43:23 PM

Document Has Been Signed on 09/10/2021 01:43 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:WHITE ROSE GUEST HOMEFACILITY NUMBER:
198603045
ADMINISTRATOR:SHINDY, TAMMYFACILITY TYPE:
735
ADDRESS:19161 ALDORA DRTELEPHONE:
(626) 581-8358
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 4CENSUS: 3DATE:
09/10/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Claudia Contreras (Administrator)TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Kruz Long conducted a Case Management visit to follow up on the death of Client #1. LPA met with Claudia Contreras (Administrator) who assisted with the visit.

During today's visit, LPA interviewed Staff #1 at 12:30 pm in the dining area. Staff #1 stated on 09/04/21 at approximately 12:14 pm, Staff #2 went to check on Client #1 in the bedroom and found Client #1 to be unresponsive. Staff #2 called Paramedics and performed CPR on Client #1 while waiting for Paramedics to arrive. Paramedics arrived in about 5 minutes and was unable to revive Client #1. Paramedics pronounced Client #1 had already passed away. Sheriffs Department arrived and interviewed Staff and conducted a facility check. Family member arrived to the facility at about 1:36 am and coroner arrived at the facility about 8:40 pm.

Copies of the following documents were obtained during today's visit:

-Facesheet
-Covid-19 Vaccine Record
-Weight Record
-Blood Sugar Log
-MAR
-Medical Notes/Appointment Log
-Medical/Specialist Visit Information
-TB and Flu Shot
-Physical Exam

Continue to LIC809C......
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WHITE ROSE GUEST HOME
FACILITY NUMBER: 198603045
VISIT DATE: 09/10/2021
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-Psychiatric Notes
-Laboratory Record
-Regional Center IPP
-Positive Support Plan
-Behavioral Services Annual Report

Facility was unable to provided Client #1's death certificate. Staff #1 was advised to provide the death certificate once available. Until cause of death is confirmed, investigation will continue.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021
LIC809 (FAS) - (06/04)
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