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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603647
Report Date: 12/31/2024
Date Signed: 12/31/2024 12:55:01 PM

Document Has Been Signed on 12/31/2024 12:55 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:KONICE CARE INCFACILITY NUMBER:
198603647
ADMINISTRATOR/
DIRECTOR:
WILSON-EKAUN, JOHNFACILITY TYPE:
735
ADDRESS:14511 NEARGROVE ROADTELEPHONE:
(562) 273-0434
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 4CENSUS: 3DATE:
12/31/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:06 PM
MET WITH:Jacinta Abanobi - DSPTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced case management visit in response to a death report received on 12/18/2024 for Client #1 (C1). LPA met with Jacinta Abanobi, Direct Support Staff (DSP) for the facility, and explained the purpose of the visit. Ifunanya Ifeacho, acting administrator for the facility, explained the purpose.

Per the Special Incident Report (SIR), C1 was taken to the hospital after complaining explaining they were not feeling well on 12/17/2024. Staff proceeded to drive C1 to the hospital, and once they arrived at the hospital C1 collapsed to the floor. Hospital staff pronounced C1 deceased shortly thereafter.

During today's visit LPA Ifunanya who explained that when they arrived at the hospital, C1 had slumped over after walking for about 10 meters, which prompted them to call hospital staff for assistance. Hospital staff proceeded to perform CPR on the client, however they did not make it.

Staff #1 (S1) emailed LPA C1's Physician's Report, FACE Sheet, Individual Program Plan (IPP), and their Medication Administration Records (MARs) for the past three (3) months. Staff explained that they will email LPA a copy C1's death certificate once it becomes available.

LPA conducted a health and safety check of the facility, including a tour of C1's bedroom. No concerns, obstructions, or anything out of the ordinary was witnessed during the visit.

No deficiencies were observed during today's visit. Exit interview was held and a copy of the report was provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE: DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/31/2024
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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