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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603438
Report Date: 03/08/2024
Date Signed: 03/08/2024 03:04:33 PM

Document Has Been Signed on 03/08/2024 03:04 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:NAGOMI HOME LLCFACILITY NUMBER:
198603438
ADMINISTRATOR:AYABE, TOKIEFACILITY TYPE:
740
ADDRESS:1128 N FAIRVALLEY AVETELEPHONE:
(626) 404-8798
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 6CENSUS: 5DATE:
03/08/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Tokie Ayabe, administratorTIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPAs) Tao and Reyes conducted an unannounced initial case management visit regarding a Health and Safety check of the facility regarding a hospice resident#1 (R1). LPAs met with Administrator, Tokie and explained the reason of the visit.

According to the incident report dated 3/7/24, R1 admitted to hospice on 9/3/23 and became bedridden on 3/6/24. Per investigation, Hospice stated R1 is bed bounded and the life expectance is less than 14 days. Administrator had contacted fire department for a fire watch during this period of time.

During today's visit, LPA interviewed administrator, R1's file was reviewed and obtained the following:
· Staff roster and resident roster
· Resident #1 (R1) facesheet dated 04/25/23
· Unusual incident report, dated 03/07/24
· Physicians report R1- R6
· R1's Vitas Healthcare plan of care, dated 3/8/24
· R1's Hospice Care Vita Information
· R1's Admission agreement.

Administrator stated she provide updates about R1 via incident report / death report. Exit interview was conducted and a copy of LIC 809 Report was provided to administrator.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2024
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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