Facility Evaluation Report

On 4/212023 at 4:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to death report received on 4/7/2023. LPA met with staff, Solange Aboke and explained the purpose of the visit. LPA spoke with Administrator, Evelyn Marquez-Uy and stated she was not able to be at the facility. Administrator stated that staff is able to sign licensing reports.

LPA received death report on 4/7/2023 for client (C1). Death report revealed that at around 9:55PM, overnight staff (S2) heard C1 making strange sounds and observed C1 was restless. C1 started shaking and still restless. 911 was called. When paramedics arrived, CPR was performed for over 30 minutes. C1 passed away on 4/5/2023.

LPA interviewed 1 staff and was informed that S2 heard C1 making sounds and called S1. C1 was conscious and moving when S1 came in the room after getting S2's call. 911 was called right away. Police arrived first followed by paramedics shortly after.

At 4:10PM, LPA request to review C1's files. However, staff did not have access to client's files. Administrator informed LPA that staff does not have the key to the office where the client files were kept.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.