Facility Evaluation Report

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced case management visit to this facility. Upon arriving at the facility, LPA met with Administrator / Zosimo Pascasio, who assisted with the visit. LPA explained the purpose of today’s visit is to follow up on the death of Client #1 (C1), which occurred on 5/16/23.

On 5/23/23, LPA Katrdzhyan conducted the initial visit to this facility and requested to review the file of C1. At the time of visit, the Administrator stated that the file was not available because the Temple City Sheriff's Department had confiscated the file of C1 and the file had not been returned back to the facility. LPA requested copies of the documents listed below to be faxed to CCL, by no later than 10am, on 5/24/23.

• Identification and Emergency Information • Physician's Report • Appraisal/Needs and Services Plan

• Admission Agreement • Temple City Sheriff's Report • Resident Appraisal • Medication Administration Record (MAR) • Consent Forms

LPA received copies of the Identification and Emergency Information, Admission Agreement, Consent for Medical Treatment, Mental & Physical Health Intake Assessment and Functional Capability Assessment. The forms were incomplete and missing the signature of C1 and/or C1's Responsible Party. The medical assessment for C1 was also missing.

The following deficiency was observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)

An exit interview was conducted and a copy of this report was provided to the Administrator along with the Appeals Rights.