Facility Evaluation Report

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management Visit to follow up on the Incident Report (SIR) and Death Report that CCL received on 12/06/2023. LPA was met by Direct Support Professionals (DSPs) Lilia Valerio, Shiela Masuelos and Eric De la Cruz and explained the reason for the visit. Flerida Resurreccion, Administrator arrived at 11am and another Administrator, Irene Genaskey, arrived at 11:50am and assisted LPA with the visit.

The incident report stated that on 12/05/2023 at 4:20am, Staff #1 (S1) gave Client #1 (C1) a piece of quesadilla while waiting for his coffee. S1 noticed that C1 was coughing and choking. S1 attended to C1 right away and performed the Heimlich procedure. Despite continuing the Heimlich procedure (5) times, C1 was still choking, so S1 immediately called 911. While S1 was talking to the 911 operator, S1 continued the Heimlich procedure to C1. The 911 operator instructed S1 to continue doing Heimlich until the paramedics arrived. At 4:35am, paramedics arrived, started doing the Heimlich procedure and tried to revive C1 for 25 minutes but was unsuccessful. The Administrators did not have the official time of death but stated it was around past 5am due to choking. Based on the records reviewed, C1 had been coughing for 3 weeks prior to seeing his doctor on 10/26/2023 at 3:26pm. C1 was diagnosed with slight left lower lobe pneumonia (community acquired pneumonia). Medication including antibiotics was prescribed for C1’s cough and was sent back to the facility.

Prior to today's visit, LPA obtained copies of C1's Death Report, Emergency and Identification Form, Admission Agreement (admitted 2/18/2020), Physician's Report (07/12/2023), and Medication Administration Records (MARs) for Nov-Dec 2023. Administrators stated that they do not have the official cause of death at this time. According to the Coroner, they ar e not done with their report yet. Per the Administrator Irene Genaskey, she will provide CCL/LPA a copy of the of Death Certificate once it becomes available. Administrators informed Harbor Regional Center of the situation.

During today's visit LPA interviewed Administrators Flerida Resurreccion and Irene Genaskey and obtained additional documents: Police Report Number 023220841332493 (Bellflower PD), C1's M and Medication Administration Record (MAR) for Oct 2023, Needs and Services Plan and/or IPP and recent Medical Assessment by C1’s Physician (10/26/2023). LPA also toured the facility including C1's bedroom. No concerns, obstructions, or anything out of the ordinary was witnessed during the visit. LPA has also requested the Administrators to obtain and provide Licensing with C1's Death Certificate upon receipt.

No deficiencies observed but a Technical Assistance was issued during today's visit. An exit interview held and a copy of the report was provided to Flerida Resurreccion , Administrator.