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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603050
Report Date: 10/09/2024
Date Signed: 10/09/2024 04:19:58 PM

Document Has Been Signed on 10/09/2024 04:19 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:MATHARU HOME #2FACILITY NUMBER:
198603050
ADMINISTRATOR/
DIRECTOR:		MATHARU, DAVEFACILITY TYPE:
735
ADDRESS:15335 CERISE AVETELEPHONE:
(310) 328-8482
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY: 6CENSUS: 3DATE:
10/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Laura Ramirez- AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 10/09/24 Licensing Program Analyst, LPA Troy Watson conducted a Case Management visit to follow up on the death reported for client t#1 (C1). LPA was greeted by Laura Ramirez and explained the purpose of the visit was to gather information about the death of (C1).

The regional office received a copy of the death report from the facility and reported the death of (C1) on 10/01/24. The death report stated on 10/01/24 (C1) was pronounced dead at 7:21: a.m. at Providence Little Company of Mary Medical Center Torrance. C1 was sent to the hospital in an emergency medical service (EMS) vehicle and was admitted to the hospital on 10/01/24 due to coughing, pale skin and slurred speach, C1 later passed away at the hospital due to cardiac arrest. Interviews conducted with staff #1-#3 (S1-S3) and clients #1- #3 (C1- C3) were performed on this visit.

The following documents were collected:
· ID and Emergency Information
· Admission Agreement
· Physician Report for Community Care Facilities LIC602A
· Preplacement Appraisal Information LIC603
· Appraisal/Needs and Service Plan
· Medications (MAR)
· Hospital discharge records

No citations issued during this visit.
An exit interview was conducted with the facility Administrator Laura Ramirez and a hard copy of this report was provided.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2024
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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