<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603784
Report Date: 07/09/2024
Date Signed: 07/09/2024 03:18:35 PM

Document Has Been Signed on 07/09/2024 03:18 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:FAITH MANORFACILITY NUMBER:
197603784
ADMINISTRATOR/
DIRECTOR:		CLAREL MARTINEFACILITY TYPE:
735
ADDRESS:1832 SOUTH ARLINGTON AVE.TELEPHONE:
(323) 737-2310
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY: 21CENSUS: 18DATE:
07/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Tompi SihamauTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Alma Gonzalez conducted a case management visit for the death of Client 1 (C1) which occurred on 12/06/22.

LPA conducted an initial visit on 12/14/22. LPA requested/ reviewed death certificate and the death certificate indicates that the immediate cause of death for C1 was Effects of Methamphetamine/ Accident. A Biopsy was not performed. An autopsy was not performed. Other Significant Conditions contributing to death were listed as None. Place of Death: Facility - 1832 S Arlington Ave., Los Angeles CA 90019, Room 1.

LPA interviewed Administrator and Staff 1 (S1) who stated that C1 had a history of drug use but not any current use. S1 stated that C1 was found unresponsive in their bed when they were conducting rounds. S1 immediately called 911 and the administrator.

Based on the available information reviewed, LPA did not note any deficiencies in reference to C1's death.

Exit interview conducted and copy of report was provided to Staff/ House Manager Tompi Sihamau.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1