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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601425
Report Date: 05/11/2023
Date Signed: 05/11/2023 03:43:41 PM

Document Has Been Signed on 05/11/2023 03:43 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:RHEMA CARE GROUP LLCFACILITY NUMBER:
198601425
ADMINISTRATOR:ANGELA NWAKAFACILITY TYPE:
735
ADDRESS:975 BARSTON AVETELEPHONE:
(626) 324-3134
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 4CENSUS: 3DATE:
05/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:04 PM
MET WITH:Angela NwakaTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced Case Mangement Visit to follow up on a Death Report faxed to the Department on 5/4/23. LPA was met by Angela Nwaka and explained the reason for the visit.

On 4/4/23 resident was admitted to hospital due to kidney failure and blood clots in lung. On 5/3/2023 at about 5pm the hospital nurse called Administrator Angela Nwaka to let her know that C1's health was declining and may not make it through the night. Administrator notified C1's family immediately. C1 expired at the hospital later that evening. Cause of death is currently unknown as facility is not an authorized representative. Administrator will provide information once regional center sends that over to the facility.

During today's visit LPA interviewed the Administrator and obtained copies of C1's FACE Sheet, Appraisal Needs & Services Plan, Physician's Report, and Medication Administration Record (MAR) for March - April 2023.

LPA requested facility to obtain and provide Licensing with C1's Death Report and Death Certificate upon receipt.

No deficiencies observed during today's visit. Exit interview held and a copy of the report was provided to the facility.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2023
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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