Facility Evaluation Report

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Romy Pino.

Today's visit was in response to a third-party report of the death of Client #1 (C1), received at the CCLD San Diego Regional Office (RO) on 03/13/2025. [See LIC 811 Confidential Names List for a description of select client identifiers used in this report.] Per the report, C1 passed away on 03/12/2025 at the hospital.

During today’s visit, LPA performed a facility tour and welfare check on remaining clients, finding they were in good/stable health. LPA briefly spoke with the caregivers present, then collected copies of and reviewed pertinent care records on C1.

Upon LPA’s arrival, he observed staff using a gait belt to tie/immobilize one of the wheels of Client #2’s (C2’s) wheelchair. C2 appeared agitated to LPA. While Licensee possessed a CCLD Exception Request and a written doctor’s order for C2 to use a wheelchair seat belt for their personal safety (i.e., to keep them from falling out), Licensee was not authorized to immobilize C2’s wheelchair, the latter of which constituted a restraining device and a violation of C2’s personal rights. [Staff explained to LPA that they had tied C2’s wheel to prevent C2 from pushing their wheelchair into the wall and causing property damage. LPA directed staff to immediately untie the wheel, which they did. C2 later calmed down during LPA’s visit.] During the facility tour, LPA observed that the facility’s fire extinguisher had not been serviced within the last twelve (12) months, as was required to maintain ongoing compliance with the facility’s existing fire clearance.