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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603631
Report Date: 12/17/2024
Date Signed: 12/17/2024 03:14:34 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/05/2024 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240805160859
FACILITY NAME:ST. SEBASTIAN'S HOME FOR THE ELDERLYFACILITY NUMBER:
198603631
ADMINISTRATOR:MCGEE, BRIANAFACILITY TYPE:
740
ADDRESS:3203 E CAMERON AVETELEPHONE:
(626) 331-7714
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY:6CENSUS: 6DATE:
12/17/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Briana McGee, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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1. Questionable death.
2. Staff did not seek timely medical care for resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to deliver findings for the allegations listed above. LPA met with Administrator, Briana McGee, and explained the reason for the visit.

The investigation consisted of the following:

On 8/7/24, LPA Chan conducted the initial investigation and gathered documents pertaining to Resident #1 and Staff. LPA also toured the facility and observed sufficient food supplies. Subsequently, the Department of Social Services Investigations Bureau (IB) Investigator, Olivia Spindola, interviewed the facility staff, residents, and family members. Reports from the West Covina Police Department and the West Covina Fire Department were obtained and reviewed.

(Continue on LIC9099C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20240805160859
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
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: ST. SEBASTIAN'S HOME FOR THE ELDERLY
FACILITY NUMBER: 198603631
VISIT DATE: 12/17/2024
NARRATIVE
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The investigation revealed the following:
Allegations – Questionable death and Staff did not seek timely medical care for resident. It was alleged that Resident #1 (R1) was unresponsive and possibly not breathing for approximately 40 minutes prior to 911 being called. IB Investigator Spindola interviewed the administrator, staff, and family member to determine findings. On 8/5/24 just before 7 am, R1 was discovered by facility staff cold to touch and not breathing. Staff contacted 911 after being instructed by the administrator. The West Covina Fire Department and Police Department arrived on scene and medical personnel performed CPR on R1. R1 was pronounced deceased at 7:26 am. Emergency personnel reports indicated that R1 was pulseless and there were no signs of foul play. It was also mentioned that the death appeared natural with no unusual markings or injuries. The police officer confirmed with the Deputy Coroner who advised the case was not a coroner case.
Facility staff and R1’s family member stated that R1 had been in poor health in the days prior to the death. R1’s family took resident to the doctor on 8/1/24 and was told by the doctor that everything looked okay.

Based on the reports and interviews gathered, R1’s death was not deemed questionable and Staff contacted 911 soon after discovering resident was not breathing.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.


An exit interview was conducted with Briana McGee. A copy of this report along with the appeal rights was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC9099 (FAS) - (06/04)
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