Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management and met with Licensee Kenne Kennemer. The purpose of this case management inspection is to follow up on a death certificate to Community Care Licensing (CCL) dated 8/15/22. LPA requested Death Certificate due to client not on hospice.

Community Care Licensing previously followed up on Death report dated 6/16/2022 reporting C1 had an unexpected death. Per death certificate issued by Sonoma County Coroner case# SD 220616005 dated 8/15/22 it was determined that C1's cause of death was Asphyxia by accident due to obstruction of airway by food bolus.

During today's visit LPA conducted interviews with staff that revealed that C1 did not have any food restrictions and was able to communicate their needs. LPA reviewed C1's records including Physician's Report dated 4/14/21 and C1's care plan dated 1/18/22. Based on records review of C1's file revealed that C1 had been seen by their Physician in a regular basis and their IPP dated 11/1/21 indicates that C1 did not have any history of eating disorder and was not in a special diet.

The Department conducted an investigation into the unexpected death of client. The investigation found the facility followed all regulation and training requirements.

No deficiencies cited during today's visit.