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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603489
Report Date: 01/04/2023
Date Signed: 04/11/2023 02:33:37 PM

Document Has Been Signed on 04/11/2023 02:33 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: 3DATE:
01/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:58 PM
MET WITH:Darlene Cetera TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management- Incident visit to follow up on Death Report (LIC 624A) submitted to this licensing agency on 01-03-2023. Client #1 (C1) was discovered unresponsive and pronounced dead at approximately 5:45am on 01-03-23. Immediate cause of death according to the death report is unknown at this time pending coroner investigation. Report states C1 diagnosed with seizures, Angelman Syndrome, Cerebral Palsy, Tremors, Autistic, Intellectual Disability, and Dysphagia. At approximately 5:35 am staff entered C1’s room and found C1 to be unresponsive. Staff called 911 and waited for paramedics. Paramedics arrived and did not attempt life saving measures according to staff. They announced she was too far gone.

During today’s visit, LPA requested and obtained a copy of C1’s file including current medical assessment (annual and monthly report), C1’s most current IPP, most recent physician’s orders, most recent Functional Capability Assessment, Admissions Agreement, Medications List, and most recent physician’s report. LPA conducted two staff interviews. LPA requested a copy of Staff #1 (S1) and Staff #2 (S2) file and contact information. Administrator will email this information by 01-06-23. LPA requested facility obtain a copy of the death certificate and forward the certificate to this licensing agency.

At this time there are no deficiencies to cite. LPA will continue to gather additional information from staff and other agencies. LPA will return once additional information is gathered.

*Amended on 01/05/23- signed electronically by Administrator Saunders on 01/05/23

Hard copy in file

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2023
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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