Facility Evaluation Report
Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding a death report LPA received for C1 on 10-02-2024. LPA met with Administrator and explained the purpose of the visit.
Death report revealed on morning of 09-30-2024, C2 was having diarrhea and was diagnosed with the stomach flu. Later in the evening, staff observed C1 having the same symptoms as C2 and followed C2's doctor's advisory as it was after-hours and unable to get in touch with the primary care physician. PRN anti-diarrhea was given to C1. On 10-01-2024 at approximately 11:40AM, primary care physician called and informed Administrator C1 may have the same stomach flu as C2, and to follow the same advisory. C1 was observed to be "fine" at lunch and diarrhea had stopped. Dinner was served at approximately 4PM. At approximately 4:10PM, C1 was in midst of eating, staff observed C1 to have irregular breathing. Staff assisted C1 to the couch, which is when Administrator arrived and witnessed C1 being transferred, having shortness of breathe. Administrator contacted 911 immediately and performed cardiopulmonary resuscitation (CPR) while waiting for emergency medical services to arrive. Emergency medical services then arrived and took over the resuscitation but was unable to revive C1.
LPA and Administrator discussed C1 went to day program day prior to incident, but did not go day of as Administrator was waiting for C1's doctor's appointment. Administrator stated both C1 and C2 goes to the same day program and is unsure how stomach flu was contacted. Administrator reported that C1 was healthy and there was no medical concerns.
LPA conducted a medication audit and review C1's medication administration record (MAR).
LPA is requesting a copy of C1 and C2's physician visit documentation, C1's PRN order for Imodium and C1's MAR, At this time, the incident remains under review by the Department until further notice.
Exit interview and a copy of the report was provided.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction