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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603660
Report Date: 02/08/2024
Date Signed: 02/08/2024 04:15:04 PM


Document Has Been Signed on 02/08/2024 04:15 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:PARKER HOMES 2FACILITY NUMBER:
198603660
ADMINISTRATOR:SURESH, BEVINAHLLIFACILITY TYPE:
735
ADDRESS:2808 BLAKEMAN AVETELEPHONE:
(714) 393-6391
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY:4CENSUS: 3DATE:
02/08/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Kevin Van Beek TIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Wong conducted an unannounced Case Management Visit to follow up on a Death Report received on 2/5/2024. LPA was met by DSP II Mayra Flores and explained the purpose of the visit. Later on, the administrator Kevin Van Beek arrived and assisted with the visit.

Per Special Incident Report (SIR) and death report, client was passed on 2/4/24 and hospice agency was called and client was taken according to the burial plan.

During today's visit, LPA interviewed the administrator and DSP II. The DSP II and administrator stated that client was hospitalized for three weeks and upon return to the facility from the hospital, the regional center nurse approved client to return with hospice. A weeks later after his returned and staff found him passed at the facility on 2/4/24. During the visit, LPA obtained the copy of client's facility medication list and hospice medication list, face sheet, Individual Program Plan (IPP), updated physician report and the discharge hospital report.

LPA also toured C1's bedroom. No concerns, obstructions, or anything out of the ordinary was witnessed during the visit. LPA will also request facility to obtain and provide Licensing with C1's Death Certificate upon receipt.

No deficiencies observed during today's visit. Exit interview held and a copy of the report was provided to the facility.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
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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