Facility Evaluation Report

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent case management visit regarding the death of Client #1. LPA met with Program Director, Rian Phillips, and the purpose of the visit was explained.

On 11/18/2019, LPA Chan conducted a health and safety check at the facility site and gathered documents pertaining to Client #1 (C-1). This visit was initiated due to C-1 passing away on 6/18/2019 as a result of choking. Due to nature of this death, the Department of Social Services Investigation Bureau (IB) Investigator Jose Santana conducted a further investigation. Investigator Santana interviewed the previous Program Director, Dameon Gordan, Staff, and Clients who were present during this incident.

The incident occurred on 6/18/2019 at Cherry Park in Long Beach, where a group of 5 clients and 2 staff stopped to eat their snacks/lunches. While staff #1 (S-1) was preparing their snacks, C-1 grabbed some chicken nuggets from a container and shoved it in his/her mouth. S-1 quickly intervened and tried to remove the food from client’s mouth using 2 fingers. S-1 told Staff #2 to perform the Heimlich maneuver, but nothing came out. C-1 walked away towards the van and Staff assumed C-1 was no longer in distress. Staff directed the clients to get back in the van so they could return to the facility. Staff noticed C-1 was seen turning blue and immediately dialed 911. S-1 followed the operator’s CPR instructions until the paramedics arrived and took over. C-1 was pronounced deceased at the scene on 6/18/2019.

The investigation revealed that C-1 required close monitoring due to the tendency of grabbing other people’s food and placing it in his/her mouth. Staff interviewed indicated that the Program Director did not inform them that C-1 required special meal preparation. Staff learned of C-1’s behavior through observations and from other Direct Services Professional (DSP) staff. The former program director failed to adequately notify DSPs about C-1’s chopped diet requirement, as specified in the Individual Program Plan. In addition, the program director did not ensure that S-1’s CPR/First Aid certification, which expired on 5/2/2019, was current at the time of incident.

Based on documentation and interviews conducted, it is determined the client choked on food and died while in care as a result of the facility’s negligence. An Immediate Civil Penalty of $500 is being issued today. Refer to LIC421IM. The issuance of an additional Civil Penalty is being assessed based on health and safety code 1548 (2)(A), if the department determines the death of the client is due to neglect.

An exit interview was held. A copy of this report, LIC421IM, and appeal rights were given to Ms. Phillips.