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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609137
Report Date: 06/10/2022
Date Signed: 06/10/2022 01:41:58 PM

Document Has Been Signed on 06/10/2022 01:41 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:GATEWAYS HOSPITAL - SOCIAL REHAB. PROGRAMFACILITY NUMBER:
197609137
ADMINISTRATOR:SANDRA LONGFACILITY TYPE:
772
ADDRESS:423 N. HOOVER STREETTELEPHONE:
(323) 300-1830
CITY:LOS ANGELESSTATE: CAZIP CODE:
90004
CAPACITY: 16CENSUS: 13DATE:
06/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Program Director Kallyn LandelTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Alma Gonzalez conducted a case management visit to follow-up on the death of Client 1 (C1). LPA met with Program Director Kallyn Landel and explained the reason for the visit. According to the death report dated 06/06/22, C1 passed away on 06/05/22. Immediate cause of death noted on LIC 624A Death Report is unknown - pending autopsy. C1 was a returning client to the facility and had been at the facility for six (6) days.

The facility provided the following documents prior to the visit:
  • Death Report LIC 624A

During today's visit, LPA reviewed C1's facility file and interviewed Program Director Kallyn Landel and Residential Manager Lizeth Villegas and copies of the following documents were provided:
  • Physician's Report for Community Care Facilities LIC 602
  • Appraisal/ Needs and Services Plan LIC 625
  • Functional Capability Assessment LIC 9172
  • Resident Appraisal LIC 603A
  • Identification and Emergency Information
  • Copy of C1's medication records for month of June 2022

Program Director Kallyn Landel was asked to provide a copy of the death certificate when it becomes available.

Exit interview conducted and copy of Report was provided to Residential Manager Lizeth Villegas.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2022
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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