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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004296
Report Date: 08/31/2022
Date Signed: 08/31/2022 02:56:22 PM

Document Has Been Signed on 08/31/2022 02:56 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:PIERCE ADULT RESIDENTAL CARE HOMEFACILITY NUMBER:
306004296
ADMINISTRATOR:ROMMEL MENDOZAFACILITY TYPE:
735
ADDRESS:3112 PIERCE AVENUETELEPHONE:
(714) 556-5102
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: DATE:
08/31/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rodolfo VillaTIME COMPLETED:
03:15 PM
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This unannounced case management visit is being conducted by Licensing Program Analyst (LPA) Ruth Martinez to follow up on a death reported to Community Care Licensing on 08/30/2022 for the death of a client on 08/28/2022. LPA arrived at facility was greeted and granted entry in the facility by caregiver. LPA spoke to Gino Manaloto, Lead Direct Support Professional via telephone call and explained the nature of the visit.

During the visit LPA was unable to obtained copies of pertinent documents, LPA requested to Gino Manaloto to submit notification to LPA Patricia Velazquez once records were ready. LPA observed clients in the living room prior to activities coordinator arriving. LPA observes clients participating in activities in the facilities backyard.

Based on the information obtained by interview on 08/22/2022 job coach from day program was at the facility providing services. Client 1 (C1) was with job coach at the facilities backyard. While eating lunch, C1 was choking on his food. Job coach reported that C1's lips started to turn blue in color and it became clear C1 was choking. Job coach immediately called over for assistance, he went inside the living room and asked for help from one of the staff. Staff 1 (S1) from the facility went out and performed first aid immediately. 911 was called, S1 performed the Heimlich maneuver. S1 was able to get the food out from C1's mouth. C1 started to breathe slowly. Paramedics then arrived and took over. Paramedics took client to hospital for evaluation. Staff was informed by hospital staff that C1 would remain in ICU due to complications. LPA advised Gino Manaloto, Lead Direct Support Professional via telephone call that further information may be required at a later date.

LPA did not observe any immediate and/or safety risks in or out of the facility at the time of visit.

This report is being reviewed with facility representatives and a copy provided to the facility.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2022
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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