Facility Evaluation Report

On April 02, 2025 Licensing Program Analyst (LPA) Nakagawa, Licensing Program Manager (LPM) Mota held an announced office meeting and met with Licensee’s Arvin Davis and Leah Davis and staff Wendenberg Martinez. The purpose of the in-formal office meeting was to discuss a self-reported incident involving the death of Client (C1).

On 9/13/24, the department received a self-reported incident report of the death of C1 after choking on food. The Department conducted an investigation along with the Deputy Coroner for Yolo County, Individual I1 (I1) into C1’s death. I1 was notified by the Coroner, a sausage about 2 ½ inches long was lodged in C1’s throat. I1 stated based off of C1’s difficulty with swallowing and eating behaviors, it would be “common sense not to feed C1 sausages.” I1 determined the cause of death was accidental and the manner of death was accidental. I1interviewed C1’s doctor who did not qualify a sausage as “soft food.” Per C1’s death certificate, C1 passed away on 9-07-2024 due to “Choking,” Per staff, C1 tended to shovel food and swallow food whole. The facility implemented a mechanically soft diet for C1 to limit them from choking as they had several incidents prior ( Note: Foods mu st be soft-textured foods that require minimal chewing). Staff fed C1 a hotdog for breakfast on 9-07-2024, which C1 choked on, and ultimately passed away. Staff admitted C1 has had choking incident in the past with hotdogs and sausage like foods, but staff continued to feed hotdogs to C1. The facility failed to follow C1’s food orders, which they implemented for C1, resulting in C1’s death.