275202056-5-12-2023-24-AS-VGON-CRRMFN-20230512093433

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 275202056
Report Date: 05/11/2023
Date Signed: 05/12/2023 09:35:15 AM

Document Has Been Signed on 05/12/2023 09:35 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	CIELO VISTA		FACILITY NUMBER:	275202056
ADMINISTRATOR:	MARK CASTILLO		FACILITY TYPE:	735
ADDRESS:	806 ELM AVENUE		TELEPHONE:	(831) 674-2180
CITY:	GREENFIELD	STATE: CA	ZIP CODE:	93927
CAPACITY: 40		CENSUS: 39	DATE:	05/11/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Administrator, Mark Castillo		TIME COMPLETED:	01:30 PM

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On May 11, 2023, Licensing Program Analyst (LPA) V Gorban met with administrator, Mark Castillo for a case management visit to follow up on a substantiated complaint allegation of failure to seek timely medical attention resulting in the death of a resident (R1).

On December 12, 2019, the Department concluded a complaint investigation which alleged that the facility staff did not seek timely medical service for a resident (R1) who passed away in the facility after complaining of pain for at least 7 hours.

The allegation regarding failure to seek timely medical service for R1 was substantiated and the licensee was cited for violating the California Code of Regulations (CCR) Title 22, § 80075 (a) Health Related Services states, “the licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services” for staff not properly assessing resident’s symptoms, and not seeking further medical attention for R1, who had been complaining of pain for more than seven hours.

The investigation revealed that on the night of January 8, 2019, R1 was yelling and crying for help. Staff responded to R1’s room and provided medication for nausea. R1 continued to complain through the morning of January 9, 2019, of stomach pain, difficulty breathing and nausea.

Report continues on LIC809 C

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CIELO VISTA	FACILITY NUMBER: 275202056
	VISIT DATE: 05/11/2023

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Based on record review and interviews during the complaint investigation, nine witnesses confirmed that R1 was crying and asking for help through the night of January 8, 2019, and into the morning of January 9, 2019. Four witnesses stated they had personally informed facility administrator (S1) that R1 looked sick and needed help on January 9, 2019, at approximately 1:00 a.m. to 3:00 a.m., 6:45 a.m., 8:30 a.m., and 9:40 a.m. At 10:45 a.m., R1 was found unresponsive in bed by a staff nurse. 9-1-1 Dispatch records showed that Police officers arrived at the facility by 10:47 a.m. and immediately performed Cardiopulmonary Resuscitation (CPR). Resuscitative measures lasted at least 30 minutes but failed. R1 was pronounced dead at 11:41 a.m.

A review of R1’s Certificate of Death Issued by the State of California-Department of Public Health dated May 06, 2019, reported the cause of death as aspiration of stomach contents as an immediate cause. Other conditions related to the cause are as follows: aspiration of stomach contents, MINS, cardiac arrhythmia, fibromuscular dysplasia of atrioventricular node artery, as well as other conditions contributing to death is intramural coronary artery.

Based on interviews and records review, the licensee failed to seek timely medical attention and higher level of care for R1, resulting in the death of a resident (R1).

At the time of the complaint visit, this case was reviewed to determine the issuance of a civil penalty based on Health and Safety Code § 1548.

The Department has concluded an analysis and has determined that a civil penalty is warranted for a death of a client in care.

Today, May 11, 2023, the Department is issuing a civil penalty per Health and Safety Code § 1548 in the amount of $15,000 for a violation that the Department determines resulted in the death of R1.

A copy of the LIC 421D was given to (facility representative) and originals were signed.

Exit interview conducted. Appeal Rights provided. A copy of the report issued. Administrator's signature on this report acknowledges receipt of these rights, found on page 2 of LIC 421D.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

LIC809 (FAS) - (06/04)

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