Facility Evaluation Report

Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced subsequent case management visit as a follow up to the case management visit that was conducted on 05/15/2025 by LPAs’ Pena and Castro. LPA met with Staff, Ian Baker and explained the purpose of the visit.

On 05/15/2025, LPAs Pena and Castro conducted a case management visit to follow up on a Special Incident Report (SIR) that was submitted by the facility dated 05/09/2025. The SIR indicated that a staff member saw Client #1 (C1) throwing up and facility staff called 911. C1 was transported to the hospital and passed away later that day.

The Department received the Death Certificate for C1 which lists the cause of death as “complications of food aspiration”. Frank D. Lanterman Regional Center conducted an investigation into C1’s death. Their investigation revealed the following: On 05/09/2025, sometime between 5:30pm and 6:00pm, Staff #1 (S1) heard a noise and went outside where they saw C1 lying on cement, vomiting. C1 was still breathing and S1 turned C1 on their side and pounded their back to dislodge food. S1 did not perform the Heimlich maneuver or do a finger sweep to dislodge food. S1 called 911 and had to leave C1 alone in order to move the other clients inside. S1 was the only staff member present at the facility with seven (7) clients at the time of the incident. C1 was transported to the hospital where they later passed.

Bancroft House is a Level 4H Home requiring 2:1 staffing during the hours from 6:00am-10:00pm due to the high service needs of the clients. This 2:1 ratio equated to four (4) staff for seven (7) clients at the time of the incident. Information obtained during the investigation revealed that the facility was not following this required staffing ratio at the time of the incident.