306003744-5-3-2024-22-AS-CGUZ-D4WQQ9-20240503122158

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003744
Report Date: 05/03/2024
Date Signed: 05/03/2024 12:22:29 PM

Document Has Been Signed on 05/03/2024 12:22 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	QUALITY CARE PLUS		FACILITY NUMBER:	306003744
ADMINISTRATOR/ DIRECTOR:	MARJAN ARASTOO		FACILITY TYPE:	735
ADDRESS:	1652 W. BROADWAY		TELEPHONE:	(714) 635-6561
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92802
CAPACITY: 80		CENSUS:	DATE:	05/03/2024
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:00 PM
MET WITH:	Marjan Arastoo		TIME VISIT/ INSPECTION COMPLETED:	12:35 PM

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	Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced case management visit for the purpose of delivering findings of the investigation into the death report of Client 1 (C1) received from the facility on December 31, 2023. LPA met with Administrator (AD) Marjan Arastoo and explained the purpose of the inspection. C1 had been diagnosed with schizophrenia effective disorder, bi-polar, depression and Acute Renal failure. C1 had kidney failure and required a kidney transplant or would require dialysis three times weekly. C1 was very upset with their prognosis and told Client 2 (C2) they were upset at their medical condition, housing situation and how they had distanced themselves from their family due to their recent marriage. C1 recently married C2, and C2 moved into the facility with C1. C1 and C2 occupied a room together at the facility. On December 27, 2023, at about 2:00 p.m., C1 told C2 that they had ingested approximately 100 tablets, the entire bottle of extra strength Tylenol at about 11:30 a.m. C2 reported that they told C1 to drink a lot of water to induce vomiting. C2 reported that C1 did vomit all the water they drank and maybe some Tylenol, but C2 was unsure if C1 was able to get all of it out of their system. C1 reported to C2 that they were fine and asked C2 not to report this incident to AD Arastoo or anyone else. At approximately 4:00 p.m., AD Arastoo said she checked in on C1 at their room and reported that C1 told her they were tired but did not report the incident to her. C1 was seen at about 5:35 p.m. downstairs at the medication room taking medications (video available). C2 said C1 was not complaining of any discomfort and appeared to be fine. C2 said they stayed up all day and night watching C1 and at approximately 03:00 a.m. on December 28, 2023, C2 noticed that C1 was not responsive and called 911. C2 informed the paramedics upon their arrival about the bottle of Tylenol and gave it to them. C2 rode to the hospital in the ambulance because they did not have a vehicle. (LIC809-C)

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: QUALITY CARE PLUS	FACILITY NUMBER: 306003744
	VISIT DATE: 05/03/2024

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C1 was treated by attending physician, who diagnosed them with, Hypothermia and Severe Sepsis. After physicians treated C1, they reported to C2 that C1 had significant liver damage beyond recovery as it would also affect their kidney function.

C1 was moved to a room when their status improved and was believed to be in fair condition for the duration of their medical treatment and had requested prior to their decline and being intubated that they did not want heroic measures taken to keep them alive. Physician noted in critical care notes that C1 presented with a condition in which there was a high probability of imminent or life-threatening deterioration. On December 31, 2023, at 02:38 p.m., C1 passed away despite the efforts by the physicians to stabilize them. Spouse, C2 informed the physicians that C1 discussed with them not to take any lifesaving efforts and requested a DNR/DNI (do not resuscitate).

Unfortunately, due to C1’s pre-existing comorbidities, all the efforts from physicians to stabilize them were not enough and C1 died from Cardiac Arrest. The facility provided a video of C1 on December 27, 2023, at about 5:35 p.m. taking their prescribed medications by the medication room. AD Arastoo reported seeing C1 and C1 appeared to look well. There were no citations issued as facility acted accordingly to the information available to them.

An exit interview was conducted, and a copy of this report was provided to AD.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

LIC809 (FAS) - (06/04)

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