Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management and met with staff Patty Kennemer. Licensee Kenne Kennemer arrived later. The purpose of this case management inspection is to follow up on a self reported incident report submitted to Community Care Licensing (CCL).

On 6/16/22 at approximate at 5:45am when Licensee was made aware by staff after being aroused from sleep by client (C2) who said "C1 is in the bathroom sleeping and I can't wake them up". Staff went to the bathroom and tried to wake them up also with no response and called Licensee who came down within a minute, Licensee shook client to arouse, but there was no response, no breathing nor pulse. Staff called 911 while Licensee started chest compressions for one minute and checked pulse/breath as instructed by 911 operator. Licensee continued compressions until the arrival of Sonoma life-support. The paramedics continued chest compressions for about five minutes and stated "I am sorry, C1 is not alive". The paramedics contacted Sonoma County Sheriff Department and Sonoma County Coroner case# SD 220616005. Responsible parties were notified.

During today's visit LPA reviewed C1's records including Physician's Report dated 4/14/21 who had a diagnosis of Developmental Disability and allergic rhinitis. C1 had been living in the facility since 9/13/2001, they were not conserved, ambulatory and non-verbal. LPA also reviewed C1's care plan dated 1/18/22 and records review of C1's file revealed that C1 had been seen by their Physician in a regular basis.

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 Licensee agreed to submit death certificate to CCL as soon as they receive it.

No deficiencies found during today's inspection.