Facility Evaluation Report

This unannounced case management inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported death report received in the Orange County Regional Office (OCRO) on 07/18/22 regarding Resident #1 (R1). LPA met with Administrator (AD) Matthew Nazareno and discussed the purpose of the inspection.

The death report states that on 07/09/22, R1 passed away at Garden Grove Hospital due to a cardiac arrest. A related incident report received in the OCRO on 07/18/22 provides the following information: R1 was 43 years old; on 07/09/22, another client reported to staff that R1 had collapsed in the bathroom; staff called 911; paramedics arrived, applied CPR to R1, and transported R1 to Garden Grove Hospital; staff notified R1’s family and doctor; and on that same day Garden Grove Hospital called and advised the facility that R1 had passed away. Per AD, the facility originally faxed these reports to the OCRO on 7/11/22, but the fax did not go through so the reports were re-faxed. AD also reported the incident to LPA by phone prior to 07/18/22 and LPA had advised AD to gather all of the information and submit a completed death report.

During today’s inspection, LPA toured the facility with AD, interviewed AD and staff, conducted health and safety checks on residents, and requested and reviewed the staff roster, resident roster, R1’s resident file, and other pertinent records.

Interviews with AD and Staff #1 (S1) confirmed the information provided in the reports received 07/18/22. AD and S1 also provided the following information: R1 had a diagnosis of schizophrenia; R1 had received doctor’s orders to limit sugar; AD, S1, and facility staff regularly encouraged R1 to follow doctor’s orders and to eat healthy, but R1 regularly drank soda and received sweet treats from visiting family; R1 had no major health issues in the last 6 months and did not complain of any symptoms, but had gained weight;