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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603408
Report Date: 05/28/2024
Date Signed: 05/28/2024 03:48:36 PM

Document Has Been Signed on 05/28/2024 03:48 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:EASTERSEALS SOUTHERN CA - WEST MAPLE RESIDENCEFACILITY NUMBER:
198603408
ADMINISTRATOR/
DIRECTOR:		VAZQUEZ, LUDMILAFACILITY TYPE:
735
ADDRESS:9621 MAPLE STTELEPHONE:
(714) 834-1111
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: 3DATE:
05/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:12 PM
MET WITH:Priscillah Houston - Administrator TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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
Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced Case Management Visit to follow up on a Death Report faxed to the Department on 5/26/24. LPA met with Administrator Priscillah Houston and explained the reason for the visit.

The Department received a Special Incident Report dated 5/26/2024 indicating the following: On 5/18/2024 C1 was observed to be having complications and suffering from cardiac arrest, 911 was called CPR was administered, paramedics arrived and were able to stabilize C1 for transfer to hospital, while in hospital C1 suffered another cardiac arrest and on 5/24/24 at approximately 11:09pm C1 was pronounced deceased.

During today's visit LPA interviewed Administrator Priscillah Houston, obtained copies of C1's FACE Sheet, Death Report, Appraisal Needs & Services Plan, Physician's Report, and Medication Administration Record (MAR) for March 2024-May 2024.

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

No deficiencies observed during today's visit.

Exit interview held and a copy of the report was provided to Priscillah Houston.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2024
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