Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management - Other Visit, and was greeted by staff Celio Buta. Administrator Hanna Peralta was available by phone and gave authorization for staff to sign the report. The purpose of this Case Management Visit is to follow up on a death report along with an incident report notifying Community Care Licensing (CCL) that on 5/4/23 client (C1) passed away.

Per death report, "on 5/2/23 around 5:45 am staff noted that client was unconscious, unresponsive and unarousable while in bed. staff called licensed staff who assessed them, C1 appeared pale but normal temperature body, breathing 10BPM, heart rate 58 BPM, BP 98/45mmHg, oxygen saturation was 78%, and non-responsive. Staff called 911, but prior to their arrival, C1 stopped breathing and no pulse was noted, facility nurse initiated CPR while in bed then they were instructed by 911 dispatcher to transfer C1 to the floor to continue CPR until paramedics arrived at approximate 6:15am. At 6:30am paramedics pronounced C1 deceased. Santa Rosa Police Department arrived to obtain information regarding the incident. Responsible parties including CCL and NBRC were notified.

During the inspection LPA reviewed C1's care notes indicating that C1 did not have any incidents was observed at baseline, alert, no distress, vitals obtained per all shifts were within normal limits, attended to day program as usual and was repositioned accordingly to doctor's orders. The Department conducted an investigation into the unexpected death of client. The investigation found the facility followed all regulation and training requirements. However, C1 was not receiving hospice services and death was unexpected so Administrator agreed to submit death certificate to CCL as soon as they receive it.

No deficiencies cited during today's inspection. Exit interview conducted with Administrator and a copy of this report was printed for the facility.