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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603489
Report Date: 06/22/2023
Date Signed: 06/22/2023 06:04:03 PM

Document Has Been Signed on 06/22/2023 06:04 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:ABOVE AND BEYOND ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198603489
ADMINISTRATOR:SAUNDERS, TONYAFACILITY TYPE:
735
ADDRESS:430 S. MOUNTAINTELEPHONE:
(951) 323-3852
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 4CENSUS: 4DATE:
06/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:13 PM
MET WITH:Tonya SaundersTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management Visit on 06/22/23 at 4:00pm. The purpose of this visit was to deliver findings based on initial Case Management visit dated 01/04/23, regarding the death of Client #1 (C1). LPA Ramirez was met by Administrator Tonya Saunders and explained the purpose of the visit.

Investigation Findings:

On 01/03/23, LPA Ramirez received Death Report (LIC 624A) and Special Incident Report indicating C1 was found unresponsive by Staff #1 (S1) and Staff #2 (S2). Staff called 911 around 5:40 am and EMS (Emergency Medical Services) arrived at the facility at 5:46 am. On 01/04/23, LPA Ramirez conducted a Case Management visit and interviewed S1, S2 and gathered pertinent documents related to this investigation. On 01/09/23, IB Referral was sent and accepted as an IB Investigation. On 03/21/23, IB Investigation found that in the 911 recording, S1 could be heard, twice, advising the 911 operator that they (S1 and S2) were performing CPR on C1 during the call. Interviews conducted by LPA Ramirez and IB Investigator revealed that S1 and S2 denied performing FIRST AID/CPR on C1 although S1 indicated to the 911 operator that they (S1 and S2) were performing FIRST AID/CPR. Investigation findings SUBSTANTIATED- NEGLECT-FAILURE TO PERFORM CPR/FIRST AID ON A CLIENT.

Based on investigation findings, deficiencies are being cited. On 06/22/23, this licensing agency issued an ORDER TO LICENSEE/FACILITY OF IMMEDIATE EXCLUSION FROM FACILITY and ORDER FOR IMMEDIATE EXCLUSION FROM FACILITY and LPA Ramirez physically served Administrator Saunders and S2.

A copy of this report, 809-D and Appeals Rights were provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
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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Document Has Been Signed on 06/22/2023 06:04 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 06/22/2023 at 05:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ABOVE AND BEYOND ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198603489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/23/2023
Section Cited
CCR
80075(a)

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80075 Health Related Services
(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services

This requirement is not met as evidence by:
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Licensee will re-train staff on how to properly respond to emergency situations according to Plan of Operation and Title 22 regulations.
Licensee will submit to LPA, re-training material and staff attendenance sheet by POC due date.
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S1 and S2 neglected to perform CPR/FIRST AID on a client while the client was found unresponsive by staff.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023


LIC809 (FAS) - (06/04)
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