306005944-4-28-2022-22-AS-RQUZ-CDWP2D-20220428105547

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005944
Report Date: 04/28/2022
Date Signed: 04/28/2022 10:55:54 AM

Document Has Been Signed on 04/28/2022 10:55 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	LAVENDER GUEST HOME		FACILITY NUMBER:	306005944
ADMINISTRATOR:	SHINDY, TAMMY		FACILITY TYPE:	735
ADDRESS:	1872 LOTUS PLACE		TELEPHONE:	(714) 351-1012
CITY:	BREA	STATE: CA	ZIP CODE:	92821
CAPACITY: 4		CENSUS: 4	DATE:	04/28/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Tani Oshodi, House Manager		TIME COMPLETED:	10:55 AM

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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz made an unannounced Case Management- Incident inspection visit to the facility. LPA Quiroz was greeted and granted entry into the facility by Direct Service Provider (DSP 1). House Manager (HM) Tani Oshodi arrived shortly after and explained the reason for the visit. LPA Quiroz, along with HM Oshodi conducted a tour of interior and exterior of facility premises.

The purpose of today’s visit is to follow up on an investigation conducted by the Department. The investigation conducted revealed the following:

On 5/01/2021, Client 1 (C1) moved into the facility. C1’s physician report May 27, 2021 lists in part that C1 had a diagnosis of: Profound intellectual disability, total blindness, Autism, and Type II Diabetes. On the evening of 8/21/2021, C1 was given dinner and their medications at approximately 7 pm, before going to bed. At around midnight, the House Manager (HM) checked to see if C1 required assistance with incontinence care. Upon further evaluation, the HM observed C1 was unresponsive and noted to not have a pulse. The HM immediately called 911 and was instructed to perform chest compressions, which were conducted. At approximately 0455 hours, paramedics arrived and C1 was pronounced deceased.

The Brea Police Homicide Department responded to the facility to investigate. Reports from the Orange County Sheriff-Coroner concluded C1’s time of death to be approximately 1:30 pm on 8/21/2021. The investigation revealed, that HM called the paramedics timely after finding C1 unresponsive in bed. Facility staff had notified C1’s Primary Care Physician Dr.Patel that C1 appeared to be weaker based on their observations. Staff reported C1 did not complaint about not feeling well and did not display any symptoms indicating they were sick. Continued on next page...

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LAVENDER GUEST HOME	FACILITY NUMBER: 306005944
	VISIT DATE: 04/28/2022

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Continued...

During the course of the investigation, concern was indicated due to C1 being diabetic and possibly not receiving their medications. Prior to moving into the facility, C1 had been receiving medications to assist in controlling C1’s diabetes. The Investigation revealed that just prior to moving into the facility, C1’s Primary Care Physician had placed Glimepiride One MG tablet and Metformin 500 MG on hold. C1’s cause of death was determined to be Lymphocytic encephalitis and meningoencephalitis with manner of death listed as natural.

There is no evidence to support that facility failed to seek timely medical attention for C1 or failed to provide medications as prescribed. The investigation did not produce substantial evidence of Neglect/Lack of care and Supervision.

No deficiencies were cited.

An exit interview was conducted with House Manager Tani Oshodi, and a copy of this report was provided at exit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

LIC809 (FAS) - (06/04)

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