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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004036
Report Date: 08/22/2024
Date Signed: 08/22/2024 11:49:03 AM

Document Has Been Signed on 08/22/2024 11:49 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:DEL SOL HOME (FAUST)FACILITY NUMBER:
306004036
ADMINISTRATOR/
DIRECTOR:		MERCI CANIA GONZALESFACILITY TYPE:
735
ADDRESS:6139 FAUST AVENUETELEPHONE:
(562) 804-2090
CITY:LAKEWOODSTATE: CAZIP CODE:
90713
CAPACITY: 4CENSUS: 3DATE:
08/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:39 AM
MET WITH:Jorgelle Catunao - Co-AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:03 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced case management visit to follow up on a death report faxed to the department on 08/19/24. LPA met with Jorgelle Catunao (Co-Administrator) and explained the reason for the visit.

During today's visit LPA Mora reviewed and obtained copies the following documents: Client 1 (C1) death report, physician's report dated: 01/26/2024, Individualized Program Plan dated 04/15/2024, medication sheets for June 2024 - August 2024, Identification and Emergency Information sheet. LPA interview administrator, Staff 1 (S1), Staff 2 (S2), Client 2 (C2), and Client 3 (C3). Based on documents reviewed C1 was 86 years old, non-ambulatory, needed assistance with all personal needs and activities of daily living (ADLs), and was conserved by the Department of Developmental Services (DDS). Per medication sheets, C1 took all medication for the past 3 months as prescribed. C1 was admitted to Coast Plaza Doctors Hospital on 08/02/2024 because C1 was suffering from pneumonia and sepsis. On 08/08/2024, C1 was transferred to Kindred Hospital in La Mirada. On 08/11/2024, C1 was intubated and placed in the ICU. On 8/19/2024 at 2:30 AM, C1 passed away. The cause of death provided to the facility from a hospital nurse was cardiac arrest.

No deficiencies were observed during this visit and LPA requested a copy of the death certificate to be forwarded to the department upon receiving it.

Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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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