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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005475
Report Date: 11/30/2021
Date Signed: 11/30/2021 02:12:31 PM

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:FOUNTAIN VALLEY SENIOR HOMES 2FACILITY NUMBER:
306005475
ADMINISTRATOR:ALMIRANEZ, ULDARICOFACILITY TYPE:
740
ADDRESS:17690 SAN VICENTETELEPHONE:
(949) 290-6006
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 5DATE:
11/30/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:49 PM
MET WITH:Uldarico "Rico" Almiranez, Licensee/AdministratorTIME COMPLETED:
02:27 PM
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Licensing Program Analyst (LPA) LPA Rosie Quiroz made an unannounced case management visit to follow up on a death report dated 11/24/2021 reported to Community Care Licensing on 11/29/2021. LPA Quiroz was greeted, COVID-19 screened and granted entry into the facility by Licensee/Administrator Almiranez, and explained the reason for the visit.

Death report dated 11/24/2021 indicated Resident 1 (R1) was visiting in his bedroom with his girlfriend. R1 was being fed chicken wings by his girlfriend and got choked. R1's girlfriend immediately called 911. Licensee/Administrator Almiranez indicated approximately 14 paramedics arrived to facility to respond to 911 call due to R1's history and diagnose of obesity.

Facility staff indicate R1 was on a cardiac controlled diet; however did not abide to cardiac controlled diet and often ordered fast food delivery, two to three times per week.

Per physician report dated 4/07/2020, R1 is diagnosed with A-Fib and Obesity. Licensee/ Administrator Almiranez indicated he received a call from Deputy Coroner's office on 11/29/2021 indicating R1's autopsy revealed massive heart attack. Family to provide death certificate to facility as soon as its available.

Facility to forward a copy of death certificate to LPA Quiroz upon receipt, and update incident report to reflect timeline of event reported during today's visit.



Exit interview conducted with Licensee/Administrator Almiranez and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
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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