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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601398
Report Date: 11/09/2023
Date Signed: 11/09/2023 02:30:54 PM


Document Has Been Signed on 11/09/2023 02:30 PM - 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:QUAIL GARDEN 2FACILITY NUMBER:
015601398
ADMINISTRATOR:ALICIA PEACOCKFACILITY TYPE:
740
ADDRESS:836 SOUTH J STREETTELEPHONE:
(925) 872-2705
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 3DATE:
11/09/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Alicia Johnston, AdministratorTIME COMPLETED:
02:55 PM
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On 11/9/2023 at 2:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Case Management visit in regards to death report received on 10/10/2023. LPA met with Administrator, Alicia Johnston.

LPA received death report on 10/10/2023 for resident (R1). Death report stated that resident was breathing slow, shallow, and profusely sweating. Staff called 911 and R1's daughter. Paramedics and R1's daughter arrived. R1 had a DNR.

LPA interviewed staff who stated that R1 was on hospice for three years prior to moving to the facility. R1 had graduated out of hospice care and was not admitted back to hospice. LPA reviewed R1's file and observed that R1's diagnosis includes end stage dementia and history of stroke. R1 had a DNR.

No deficiency is being cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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