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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850243
Report Date: 02/11/2025
Date Signed: 02/20/2025 02:25:59 PM

Document Has Been Signed on 02/20/2025 02:25 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:LAUREL HEIGHTSFACILITY NUMBER:
565850243
ADMINISTRATOR/
DIRECTOR:
JOHNNY ORTIZFACILITY TYPE:
740
ADDRESS:13960 PEACH HILL DRIVETELEPHONE:
(805) 292-0700
CITY:MOORPARKSTATE: CAZIP CODE:
93021
CAPACITY: 112CENSUS: 72DATE:
02/11/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Johnny OrtizTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Zabel Chochian conducted a Case Management – Incident visit. Upn arrival LPA met with Executive Director (ED) Johnny Ortiz. Reason for visit was explained.

The reason for today's inspection is to follow up on a self reported incident report received on 02/10/2025. The report pertains to an incident involving Resident #1 (R1) . It was reported that on 2/01/25, R1 sustained an unwitnessed fall at the facility. R1 sustained a bump on the back of the head therefore 911 was called and resident was transferred to Los Roblas Hospital ER; 02/02/2025, R1 was discharged from ER at approximately 3am. R1 was put on a 72 hour monitoring upon return from the hospital. On 02/04/2025, R1 was observed not feeling well therefore 911 was contacted and resident was transferred to ER again. On 02/06/2025, facility was notified by R1's responsible person that R1 had passed way. Per the information received, the circumstances surrounding the death of R1 on 02/06/2025 may be questionable.

During today's visit, the LPA conducted interview with the ED and facility's Health Service Director-Pricila Bosdoganian; copies of pertinent documents requested including but not limited to a copy of the death certificate/report. LPA informed ED that this incident was referred to Community Care Licensing Investigations Branch (IB) for review and that further review is required.

An LPA will return at a later date to issue findings.

Exit interview conducted. A copy of the report was
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2025
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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