Facility Evaluation Report

On October 23, 2025, Licensing Program Analyst (LPA) Ernand Dabuet conducted a case management visit to follow up on the reported death of Client #1 (C1). Assistant Administrator Mata Fonopo greeted the LPA. The LPA explained that the purpose of the visit was to gather information regarding the circumstances surrounding (C1's) death.

The regional office received a copy of the death report on October 22, 2025, from the facility that had reported (C1's) passing on October 19, 2025. The death report indicated that (C1) passed away while being on the way to breakfast, during a medical evaluation at Southern California Hospital in Culver City. A family representative informed the facility about (C1's) passing, but no further details were provided. According to the facility, (C1) was hospitalized on September 18, 2025, and discharged on October 8, 2025. (C1) returned to Southern California Hospital for further medical observation on October 11, 2025, and unfortunately passed away in the hospital on October 19, 2025.

ID and Emergency Information (dated: 03/12/25)

Physician Report for Community Care Facilities LIC 602A (dated: 01/29/25)

Preplacement Appraisal Information LIC 603 (dated: 03/27/25)

Medications Administration Record (MAR) (dated 10/08/25 through 11/07/25)

Medical Records from Southern California Hospital (dated: 09/25/25)

An exit interview was conducted with Mata Fonopo and a copy was provided.