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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603427
Report Date: 09/09/2022
Date Signed: 09/09/2022 04:25:17 PM

Document Has Been Signed on 09/09/2022 04:25 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:HORST HOME CAREFACILITY NUMBER:
198603427
ADMINISTRATOR:ANSELMO, YETZIRAFACILITY TYPE:
735
ADDRESS:19518 HORST AVETELEPHONE:
(562) 215-3265
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 4CENSUS: 3DATE:
09/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Yetzira Anselmo, AdministratorTIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit for the death of Client #1 (C-1). LPA met with Administrator, Yetzira Anselmo, and explained the purpose of the visit.

The facility submitted a death report for C-1 who passed away on 8/27/22 at the facility. According to the death report and interview with the Administrator, C-1 was tested positive for COVID-19 back on 7/18/22 and was hospitalized from 7/18 through 8/7/22. C-1 was discharged with a CPAP order and oxygen to be used while at home with home health visitations. On 8/25/22, it was reported to the primary and pulmonologist doctors that C-1 had phlegm, congestion, and made crackling noises. C-1 was seen by the pulmonologist doctor the next day and was prescribed a new antibiotic. On 8/27/22, C-1 was found unresponsive at approximately 3 AM by the Administrator. 911 was immediately called and performed CPR. The paramedics came and tried to resuscitate the client.

LPA obtained copies of the following documents: Face sheet, Physician's Report, MAR log for August 2022, and Regional Center quarterly report.

LPA also requested for a copy of the death certificate when it becomes available.

An exit interview was conducted and a copy of this report was provided to the Administrator.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022
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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