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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603217
Report Date: 01/08/2024
Date Signed: 01/08/2024 02:37:31 PM

Document Has Been Signed on 01/08/2024 02:37 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: 2DATE:
01/08/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jorgelle Catunao – Asst. Administrator TIME COMPLETED:
03:30 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 by CCL on 12/16/2023 for Client #1 (C1). LPA met with Jordan Santos, Direct Support Professional and Jorgelle Catunao, Assistant Administrator and explained the purpose of the visit.
The incident report notified CCL of the passing of C1 at 3:20am on 12/16/2023 at Kindred Hospital in Paramount. C1 has been hospitalized at Lakewood Regional Medical Center since 10/24/2023 and was later transferred to Kindred Hospital in Paramount on 11/17/2023 due to her medical condition not improving. According to the death report, C1 has multiple pre-existing medical conditions. The incident report also stated that on 12/14/2023, a health staffing was conducted which was attended by C1's sister/conservator, the medical team of Harbor Regional Center and Kindred Hospital. It was decided that C1 will be placed on hospice and return to the facility the following week.

During today's visit, LPA interviewed the Assistant Administrator and stated that at around 8am on 12/16/2023 C1's sister/conservator called the facility to notify the staff of C1's passing at the hospital. Staff communicated the event to the other staff members. Licensee then instructed staff to do an inventory list of C1's personal belongings and set them aside for C1's family member to pick up. On the same day, staff submitted an incident report and death report to CCL and Harbor Regional Center. Per the Asst. Administrator, C1 has been hospitalized since October 2023 at Lakewood Medical Center due to a medical condition and was later transferred to Kindred Hospital in Nov. 2023 to finish the treatment.

LPA also obtained copies of C1's Identification and Emergency sheet, Appraisal Needs & Services Plan, Medication Administration Records (MARs) for Sep. 2023 - Oct. 2023, Physician's report and Incident Report/Death Report (dated 12/16/2023) submitted to CCLD & Harbor Regional Center. 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 Assistant 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 Jorgelle Catunao, Asst. Administrator.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2024
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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