306005554-7-13-2023-22-AS-SSAS-CTQTYB-20230714150828

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005554
Report Date: 07/13/2023
Date Signed: 07/13/2023 10:01:09 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/19/2022 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220719161648

FACILITY NAME:	DEVOTED HEART CARE HOMES LLC		FACILITY NUMBER:	306005554
ADMINISTRATOR:	KEVIN CLARK		FACILITY TYPE:	735
ADDRESS:	26665 AVENIDA SHONTO		TELEPHONE:	(818) 384-9331
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	4	CENSUS: 2	DATE:	07/13/2023
		UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Rafael Carbajal, Administrator		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Questionable death- staff failed to establish and follow a care plan to check on client periodically due to his history of multiple seizures.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit for the purpose of delivering the findings into the above allegation and met with Care Staff Isabel Tamanis. Administrator Rafael Carbajal arrived at the facility approximately 9:27am. On July 21, 2022, LPAs Albert Marin and Celine De Perio initiated the 10-day complaint investigation received by the Department on July 19, 2022.
On the allegation of a questionable death, it was alleged that the staff failed to establish and follow a care plan to check on Client 1 (C1) periodically due to a history of multiple seizures. The following are the findings investigated by the Department which involved record review and interviews:

On January 17, 2022, C1 was admitted to the facility. On June 25, 2022, C1 was discovered non-responsive and declared deceased. Per Medical Record dated May 10, 2022, C1 was diagnosed with Mild Intellectual Disability, Cerebral Palsy, and Severe Generalized Epilepsy where C1 experienced having on an average more than one seizure per day with the onset of age three.
Continued on LIC9099C..

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220719161648

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: DEVOTED HEART CARE HOMES LLC	FACILITY NUMBER: 306005554
	VISIT DATE: 07/13/2023

NARRATIVE

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The Orange County Sheriff’s Department’s Incident Report dated June 25, 2022 and C1’s Individual Program Plan (IPP) dated June 3, 2021, documented a history of challenging behaviors which included Suicidal Ideations (SI). The SI episodes were displayed multiple times upon starting the facility; and as a result, Risperidone was prescribed on May 17, 2022.

It was alleged that Risperidone was one of the contributing factors to C1’s death. Four interviewed facility staff along with C1’s placement agency, Regional Center of Orange County (RCOC), responded to the family’s request to discontinue Risperidone by explaining the importance of following doctor’s orders and redirected the family to discuss their concerns with C1’s psychiatrist. Both medical doctors who treated C1 confirmed that C1’s medical conditions including, Cerebral Palsy and Epileptic Seizures, were the contributing factors to C1’s death and that psychiatric medications including Risperidone would not affect or increase the probability of experiencing a seizure or to cause C1’s death. Both doctors asserted that the Risperidone was appropriate based on the behaviors C1 presented and that they have not been questioned by the family to dispute the medication.

Regarding the allegation of staff failing to establish and follow a care plan to periodically check C1, the facility is a Level 4G that houses clients with behavioral challenges or diagnosis. Since C1 was known to experience seizures and falls, a request for a daytime one-on-one aid was approved effective March 1, 2022, as noted per the RCOC Authorized Service agreement. Approved service hours were Monday through Friday from 11am to 6pm (7 hours), and Saturday and Sunday from 10am to 8pm (10 hours). Based on these approved hours, C1 did not require supervision during the evening. It was corroborated by facility staff, RCOC representatives, and Behavioral Management Assistant that C1 did not require nocturnal safety checks. RCOC representatives indicated that no incident reports had been reported regarding night seizures and disturbances by the facility. The facility staff indicated that although the IPP did not require bed checks, clients’ safety checks were done out of good judgement and completed the checks the night of C1’s death.

Continued on LIC9099C...

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220719161648

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: DEVOTED HEART CARE HOMES LLC	FACILITY NUMBER: 306005554
	VISIT DATE: 07/13/2023

NARRATIVE

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The Orange County Death Certificate dated July 7, 2022, listed the cause of death are: 1) Probable Seizure, 2) Epilepsy, and 3) Cerebral Palsy; however Obstructive Sleep Apnea (OSA), was not a contributing factor of death. Three out of three staff denied C1 being diagnosed with OSA and issued with the CPAP machine. C1’s doctor disclosed a referral was made to see the pulmonologist at the Children’s Hospital of Orange County (CHOC) to “rule out” OSA due to C1 occasionally snoring and gasping during sleep. The doctor confirmed upon review of the medical chart that there were no notes or documentation C1 needing electroencephalogram (EEG). Per facility staff, the family canceled the EEG testing scheduled on June 24, 2022, the day before C1’s death. The doctor also confirmed that there were no notes or test results from the pulmonologist on file including the consult notes from CHOC and denied C1 having OSA.

Based on the review of obtained records and the information gathered through interviews, the allegation: Questionable death- staff failed to establish and follow a care plan to check on the client periodically due to history of multiple seizures is deemed UNSUBSTANTIATED.

An exit interview was conducted, and a copy of this report including the LIC9099C, and the LIC811 were provided to Administrator Rafael Carbajal during this visit.

End of Report

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC9099 (FAS) - (06/04)

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