Facility Evaluation Report

Licensing Program Analyst (LPA) Tena Herrera conducted unannounced Case Management visit, to address and issue a citation on the deficiency observed during the complaint investigation on complaint # 28-AS-20260605113619. LPA met with Yina Figuero a and explained the purpose of today's visit, LPA spoke with Administrator Nilesh Makwana and discussed report and citation issued via phone call.

During the investigation of the above mentioned complaint LPA obtained Client #1's seizure log. On 6/1/26 C1 experienced a total of 10 seizures from 9:55pm to 10:57pm. Each seizure was within minutes of each other beginning at 9:55pm, 10:07pm, 10:11pm, 10:17pm, 10:20pm, 10:35pm, 10:41pm, 10:47pm 10:56pm, the last documented seizure was at 10:57pm. Per C1's Death Certificate the time of death was documented at 11:49pm and C1 passed at the facility. Interview with S1 revealed that they were informed of C1's first seizure via phone call and immediately made their way to the facility to monitor C1 and their seizures, S1 stated they called 911 once C1 appeared to be unresponsive and pale/blue in color. Interview with S2 revealed they were present when C1 experienced their first seizure and immediately called S1 to report and be provided with proper protocol, S2 stated the seizures were increasing in time/length and 911 was not called as S2 was instructed not to as S1 was on their way to monitor the seizures and S1 did not believe that 911 had to be called at the time. Per S1, S2 and C1's IPP, C1 had not experienced a seizure since 2009. Per the instructions listed on the Seizure Record, it states that in cases of prolonged seizures, recurring seizures call to get professional help. Since 911 was not called until after the 10th seizure was experienced it is determined that C1 was not provided medical attention in a timely manner and LPA is issuing a citation that will be detailed on the LIC809D page.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit is documented on 809D. Exit interview held and a copy of the report along with appeal rights were provided.