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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601446
Report Date: 08/03/2023
Date Signed: 08/03/2023 10:37:50 AM

Document Has Been Signed on 08/03/2023 10:37 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GATEWAYS NORMANDIE VILLAGE EASTFACILITY NUMBER:
198601446
ADMINISTRATOR:SANDY LONGFACILITY TYPE:
735
ADDRESS:1355 SOUTH HILL STREETTELEPHONE:
(213) 389-5820
CITY:LOS ANGELESSTATE: CAZIP CODE:
90015
CAPACITY: 60CENSUS: 48DATE:
08/03/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:- Office ManagerTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced Case Management Visit to follow up on a Death Report faxed to the Department on 7/27/23. LPA was met with Office Manager Nuri Sanchez and Residential Manager Alex Rojas who later assisted with the visit, the purpose for the visit was explained.

During today’s visit LPA interviewed Staff 2 (S2) and Staff 3 (S3). Prior to today’s visit, LPA obtained copies of C1’s Session Information/Problem List, Death Report, Identification and Emergency Information, Physician’s Report, Medication Administration Record (MAR) from May 2023 – June 2023. Today LPA obtained copies of Staff Roster, Client Roster, admission agreement and C1’s FACE Sheet.

Per interview with S2 and S3 prior to AWOL of C1 there were maniac behaviors and claims of pain that C1 was experiencing. Days leading to C1’s AWOL there were visits with the Nurse Partitioner, Hospital (ER) and Psychiatrist with attempts to help client with the symptoms they were experiencing. Unfortunately, client AWOL from facility at approximately 12:30pm on 6/23/23 and expired shortly after on 7/9/23 at a hospital. Time of death and reason are unknown at the moment, facility is waiting for the Death Certificate to be provided for that information.

LPA is requesting facility to obtain and provide Licensing with C1’s Death Certificate upon receipt.

No deficiencies observed during today’s visit. Exit interview and a copy of the report was provided to Clinical Supervisor/ Intake and Discharge Coordinator Brynne MacPhail.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2023
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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