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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004423
Report Date: 04/11/2023
Date Signed: 04/12/2023 08:17:52 AM

Document Has Been Signed on 04/12/2023 08:17 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
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:
04/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Eva Gallardo , House Manager TIME COMPLETED:
09:50 AM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced case management visit. LPA met with House Manager Eva Gallardo and explained the purpose of the visit.

Licensing received an incident report of client death on 3/26/23 for Client #1 (C1). Report stated that around 5:57pm. C1 was being served dinner in pudding consistency when they began to choke. Staff present immediately assisted C1 but was unable to clear airway so 9-1-1 was called. 911 instructed staff to continue what they were doing until paramedics arrived. According to interviews and incident report, the paramedics arrived by 6:10pm and C1 still had a pulse. Paramedics continued CPR, C1 lost pulse at 6:24pm and paramedics continued until 6:42pm when they stopped as they could not longer get a pulse.

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 #3 (S3) and Staff #4 (S4). Interviews stated that on 3/25/23, C1 had a normal day up until the incident started at night. C1 eats their meals in a pudding thick consistency per doctors orders and staff assist as C1 will sometimes regurgitate food. LPA confirmed from C1's file review that C1's meals are to be in a pudding thick consistency. Interviews stated C1's family was notified right aware as well as C1's placement agency.

Facility 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: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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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