<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200876
Report Date: 10/22/2024
Date Signed: 10/22/2024 11:45:17 AM

Document Has Been Signed on 10/22/2024 11:45 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ADULT PACIFIC CARE INCFACILITY NUMBER:
079200876
ADMINISTRATOR/
DIRECTOR:		MEZA, CLAUDIAFACILITY TYPE:
735
ADDRESS:2024 ALVARADO DRTELEPHONE:
(925) 978-4425
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 3DATE:
10/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Anthony Juiguinta Cancho, Direct Support ProfessionalTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/22/2024 at 11:00am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 10/19/2022. Claudia Meza, Administrator arrived at 11:20am and LPA explained the purpose of the visit.

The incident occurred on 10/18/2024 regarding C1. S1 stated C1 had a normal day. C1 attended a community outing, returned home and watched television. S1 stated C1 went to his room and S2 heard a grunt sound coming from a bedroom, checked and saw C1 with his head facing up. Staff called 9-1-1 due to C1 not responding or breathing. Cardiopulmonary resuscitation (CPR) was given, officers arrived, paramedics arrived and took over chest compressions. C1 was taken to the hospital where he was pronounced deceased.

LPA L. Hall collected C1's appraisal needs and services plan and physician's report. documents pertinent to the incident report.

No deficiencies issued during the visit.

Exit interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1