Facility Evaluation Report

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Analicia Tavarez, House Manager. Licensee, Michael Stanek arrived during the visit.

During today’s visit, LPA briefly toured the facility, collected and reviewed care records on Client 1(C1), and interviewed staff. LPA performed a welfare check on the clients in care, finding no immediate safety concerns.

Today's visit was in response to Licensee’s self-reported death of Client #1 (C1), received at the CCLD San Diego Regional Office on 08/18/2025. Per the report, C1 had an incident of choking on 08/07/2025 while eating breakfast. Interviews revealed the staff that was at the facility with the client performed the Heimlich maneuver on C1 and was unable to dislodge the food to clear the airway. The staff called 911 and started to immediately follow 911 dispatch's instructions. Interviews revealed the staff started CPR while on the phone with 911 and did CPR until the paramedics arrived. C1 was then transported to the hospital.

Interviews revealed that C1 was in good/normal health that day, with no sign of illness, coughing, and that the choking began while eating breakfast. C1 was hospitalized and in the ICU for further monitoring. C1 passed away at the hospital on 08/17/2025 due to no positive change in C1s condition and was pronounced with having cardiac death.

During a review of records, LPA observed and manager interview confirmed: C1 began eating breakfast around 6:50 am before leaving for program around 8am. Licensee possess a completed LIC 602 Physician’s Report dated 11/26/2024 on C1, as was required. C1s documented diagnosis is Developmental Delay and Schizophrenia.

No deficiencies seen or cited during todays visit.

An exit interview was conducted with Licensee, Michael Stanek, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.