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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004423
Report Date: 11/10/2022
Date Signed: 11/10/2022 04:40:23 PM

Document Has Been Signed on 11/10/2022 04:40 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:ELWYN NC - LARRYLYNFACILITY NUMBER:
306004423
ADMINISTRATOR:TERESA OPORTOFACILITY TYPE:
735
ADDRESS:10915 LARRYLYN DRTELEPHONE:
(562) 315-5505
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY: 4CENSUS: 3DATE:
11/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Administrastor Edward Velarde TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced case management visit. LPA met with Administrator Edward Velarde and explained the purpose of the visit.

Licensing received an incident report on 11/1/22 of Client #1 (C1) being hospitalized on 10/31/22 due to low oxygen levels and difficulty breathing. Report stated that around 9:15pm staff noticed C1 to have issues breathing and C1 was given oxygen until paramedics arrived and transported C1 at 9:35pm to PIH Whittier Hospital. Report received also stated that C1 passed away at PIH Whittier Hospital on 11/1/22 at 1:01am. A Death report was also received on 11/1/22.

During the visit LPA obtained staff, resident roster, C1s Identification and Emergency Information, physician’s report, Individual Program Plan (IPP), and medication log. During todays visit LPA conducted a health and safety check and toured the physical plant. LPA observed the food supply. LPA observed sharps, medications, and chemicals under lock. There were no health and safety concerns at the time of the visit.

LPA interviewed the Staff #1 (S1) and Staff #2 (S2). Interviews stated that on 10/31/22, C1 had a normal day up until the incident started at night. C1 had a history of aspiration pneumonia; therefore, staff monitor and are able to provide oxygen to C1 when needed. Before going to bed C1 showed signs of struggling to breathe and staff #3 (S3) assessed C1 and notified paramedics while providing oxygen to C1. C1 was still alive at the time that Paramedics arrived and took C1 to the hospital at 9:35pm. C1 passed away at PIH Hospital. C1's responsible party and placement agency were notified.

Administrator to obtain a copy of death certificate and provide to Licensing when available.

Exit interview was conducted and a hard copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2022
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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