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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603217
Report Date: 10/09/2023
Date Signed: 10/09/2023 03:30:05 PM

Document Has Been Signed on 10/09/2023 03:30 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:DEL SOL HOME (CARPINTERO)FACILITY NUMBER:
198603217
ADMINISTRATOR:GONZALES, MERCIFACILITY TYPE:
735
ADDRESS:17926 CARPINTERO AVETELEPHONE:
(562) 243-4234
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: DATE:
10/09/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:48 PM
MET WITH:Anna Marie Tomilloso - AdministratorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced case management visit to follow up on the SIR/Death Report received on 10/05/2023 for Client #1 (C1). LPA met with Petronila Adlaon, Direct Support Professional and explained the purpose of the visit. At 1:58pm, Anna Marie Tomilloso, Administrator arrived and assisted LPA with the visit.

The incident report notified the passing of Client #1 (C1) at 3:22am on 10/05/2023. At around 3:00am, Staff #1 (S1) noted that C1 was unresponsive and started performing CPR and 911 was contacted immediately. Paramedics continued performing the CPR and tried to revive C1 but was pronounced dead at 3:22am. The staff then notified the family member/conservator and Harbor Regional Center of C1's passing. The family member coordinated with the Mortuary to pick up C1's body.

During today's visit LPA interviewed the Administrator and stated that upon finding C1 unresponsive, S1 immediately checked C1's vital signs and did physical/body checks. S1 determined that Autosat was very low (77-78) and started performing CPR and 911 was contacted immediately. Staff also called the Administrator. Paramedics arrived approximately 5-10 minutes later, and continued performing the CPR and C1 was pronounced dead at 3:22am. Lakewood Police arrived shortly after and inspected C1's body and talked to the Staff. At around 7:30am, staff was able to contact the family member who coordinated with the Mortuary to pick up C1's body. Administrator stated that Paramedics declared the cause of death to be of natural causes.



Prior to the visit LPA obtained copies of C1's FACE sheet, IPP (6/21/2023), Client Development & Evaluation Report (CDER - dated 6/21/2023), Medication List (Oct. 2023), Facility Report (9/15/2023), Notes from Primary Doctor (10/03/2023) and Incident Report/SIR (10/05/2023) submitted to CCLD & Harbor Regional Center. During the visit, LPA obtained C1's latest Physician's Report (3/20/2023).

LPA also toured C1's bedroom. No concerns, obstructions, or anything out of the ordinary was witnessed during the visit. LPA has also requested the Administrator to obtain and provide Licensing with C1's Death Certificate upon receipt.

Based on the interview and records reviewed, LPA did not observe any deficiencies in reference to C1's death.

Exit interview conducted and copy of report was provided to Anna Marie Tomilloso, Administrator.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2023
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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