Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management and met with staff Antonio Bulalacao. Administrator Dan Martin was unable to come to the facility due to been out of the area, but gave authorization to staff to sign the report. The purpose of this case management inspection is to follow up on a self-reported death report submitted to Community Care Licensing (CCL) on 10/6/25.

On 10/6/25 the department received death report and supporting documents (hospital notes) from the facility. Per death report, on 09/29/2025, client (C1) was brought to novato hospital, where they were diagnosed with sepsis and recurrent aspiration pneumonia, acute hypoxic respiratory failure, acute pancytopenia, and severe aortic stenosis. report continues to state that client was in hospital from 09/29/2025-10/05/2025. The Administrator was contacted by the department to request death certificate to be submitted for review and it was agreed that they will submit it once receive it.

During today's visit LPA requested C1's records including Physician's Report, chart notes and care plan. According to Administrator, C1 did not have a change of condition prior to hospitalization.

The Department will be reviewing documents once received to investigate the unexpected death of client die to C1 was not receiving hospice services and death was unexpected so Licensee agreed to submit death certificate to CCL as soon as they receive it.

No deficiencies found during today's inspection.