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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004750
Report Date: 12/13/2021
Date Signed: 12/13/2021 12:19:04 PM

Document Has Been Signed on 12/13/2021 12:19 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:EASTWOOD CARE HOMEFACILITY NUMBER:
306004750
ADMINISTRATOR:ANNA MALLARIFACILITY TYPE:
740
ADDRESS:8426 CHOPIN DRIVETELEPHONE:
(714) 735-9004
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 6CENSUS: 4DATE:
12/13/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:38 AM
MET WITH:Paulo FaeldoTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on a incident report submitted to Community Care Licensing on 12/09/2021. LPA was greeted and granted entry into the facility by Caregiver Paulo Faeldo and explained the reason for the visit.

Incident report dated 12/09/2021 indicated that Client 1 (C1) had passed away at Anaheim Medical Center on 12/07/2021. Interview conducted with Caregiver Faeldo indicated C1 had been sent to the hospital after coughing and having blood oxygenation levels in the low 70's. The client was having difficulty breathing and caregiver was in consultation with C1's primary care physician. Client had a "Do Not Resuscitate" on file. Family member advised facility that client had passed while at the hospital. Facility to request a copy of the death certificate from family and forward to LPA. Per physician report dated 06/09/2021, Client was diagnosed with Dementia. Client admitted into the facility in August 2021 after a prior hospitalization. The investigation remains ongoing.





Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2021
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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