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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603607
Report Date: 09/25/2023
Date Signed: 09/25/2023 10:40:06 AM

Document Has Been Signed on 09/25/2023 10:40 AM - 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:SPRINGFIELD MANORFACILITY NUMBER:
198603607
ADMINISTRATOR:BAIG, SHAHBAZFACILITY TYPE:
735
ADDRESS:2526 NEW AVENUETELEPHONE:
(818) 846-4469
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 32CENSUS: 31DATE:
09/25/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Jaem Tan, Assistant Administrator TIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit regarding the death a client. LPA met with Assistant Administrator, Jaem Tan, and explained the purpose of the visit.

The department received notification of Client #1's (C1) death on 9/21/23. C1 passed away on 9/20/23 at the facility. It was reported that on 9/20/23, C1 was in the bathroom #5 and was taking longer than usual. Staff went to check on client and found C1 lying unresponsively in the bathtub. 911 was called. Staff was performing CPR until paramedics arrived and took over. C1 was later pronounced dead at 3:13pm.

During the visit today, LPA interviewed the Assistant Administrator, Staff #1, and a Client. Per interviews, C1 appeared to be doing ok and acting normal self prior to passing. They stated C1 had a history of seizures.
LPA reviewed C1's file and was medication compliant. C1 saw the doctors regularly.

LPA requested for a copy of the death certificate once it is obtained. An exit interview was held and a copy of this report was given to Ms. Tan.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2023
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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