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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004025
Report Date: 02/03/2023
Date Signed: 02/03/2023 03:22:56 PM

Document Has Been Signed on 02/03/2023 03:22 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PLAZA DE MADRIDFACILITY NUMBER:
306004025
ADMINISTRATOR:MARY GONZALESFACILITY TYPE:
735
ADDRESS:20120 PLAZA DE MADRIDTELEPHONE:
(562) 865-6095
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 4CENSUS: 3DATE:
02/03/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Administrator - Mary GonzalesTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Ashley Calderon conducted a unannounced Case Management Visit in reference to the Death of Client #1 (C1). LPA met wirh LVN Bryawna Farmer and shortly after met with Administrator Mary Gonzales.

During the visit LPA Calderon toured physical plant with Mirafy Lopez.
LPA collected staff and resident roster, C1 Facesheet, Individual Family Service Plan, Food Menu, Staff #2 CPR certificate and Police Report Number: #CER23015-0114. On 1/30/23 C1 documents were reviewed by LPA Calderon. The following was reviewed:
Medication Log (MARS) dated for December 2022 and January 2023
Any relevant SIRs LIC 624 : 5/22/22, hospital admission for Hypotension and weakness.
Medical Assessment/Physician Report dated 9/23/22
Appraisal Needs and Services Plan dated 8/25/22
Emergency and Identification Form LIC 601 dated 8/25/21
Recent medicals records : 10/15/21 Colposcopy EMR Report, 3/16/22 Doctor Visit , 4/6/22 Gastroenterology Test Report , Memorial Care GI Procedure Summary Records / Patient Notes dated 3/3/1/22 and Gastroenterology Follow up Visit Report dated 8/25/22 (states allergic to Barbiturates- a class of depressant drug)

Continuation on Page 9099-C...
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PLAZA DE MADRID
FACILITY NUMBER: 306004025
VISIT DATE: 02/03/2023
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On 1/25/23, day of incident C1 had no changes in health conditions or behaviors, C1 finished dinner , modified diet was given: purees. C1 used restroom with Staff #2 (S2) assisting, C1 started to breathe heavily. One staff called LVN, LVN mentioned to provide oxygen to C1 as vital signs were measured and oxygen read 70. The other staff present called 911, instructed to preform CPR, staff preformed CPR, EMT arrived continued CPR and gave C1 IV fluids. Paramedics pronounced C1 had expired at 5:54pm, Deputy Granados from Cerritos Police Department was present.

Administrator Mary stated: The cause of death has not been determined. C1 was conserved by Department of Developmental Services (DDS). C1 was a Harbor Regional Center (HRC), HRC was notified on day of C1 expiration date.

P&I will return to Trust Management Services which is the payee, contracted by Harbor Regional Center.
Personal Belongings: Harbor Regional Center stated clothes most likely will be donated. Medication returned to Austin Drug Pharmacy.

LPA requested Death Certification to be faxed to CCLD when document is obtained. No immediate health concerns were noted. No deficiencies cited.

An exit interview was conducted a copy of todays report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC809 (FAS) - (06/04)
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