Facility Evaluation Report, 03/07/2024 — Saint Roque Family Home Care, Oxnard CA

Allegation: Staff did not seek medical attention in a timely manner, which resulted in client’s death.

Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent case management visit to deliver findings for the above allegation. LPA met with staff Carmen Constantino and explained the reason for the visit. Administrator Barbara Browning arrived at the facility at 2:54 p.m.

On 09/28/2023 at 10:18pm, the facility administrator called Community Care Licensing (CCL) and left a message reporting that Client #1 (C1) had passed away. According to the administrator, the staff went to check on the clients before they went to bed and noticed C1 was not in bed. The staff checked outside and found C1 outside. C1 was breathing initially but then stopped and the staff administered CPR until the paramedics arrived. Paramedics worked on C1 for 45 minutes before C1 was pronounced dead. According to the administrator, C1 did not have any recent change in conditions or decline in health. The administrator stated earlier this year C1 started losing weight and was seen by the doctor who referred C1 to a hematology doctor. According to the administrator, C1 had blood work on 09/14/2023 and it came back normal.

On 10/03/2023, between 9:40am and 11:25am, Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Incident visit. At 9:40am, LPA Peraldi met with the staff and explained the reason for the visit. At 9:56am, the administrator arrived at the facility. The reason for the visit was to follow up on a self-reported death report received on 09/28/2023. The report pertained to the death of C1. At 9:56am, an interview was conducted with the administrator and Staff #1 (S1). At 11:06am, the LPA conducted a brief tour of the facility. During the time of the visit, the LPA obtained copies of pertinent documents. The administrator was informed a referral was made to the Community Care Licensing Division (CCLD) Investigation Branch (IB) and an additional report would follow if warranted.