<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005755
Report Date: 07/11/2023
Date Signed: 07/12/2023 08:04:23 AM


Document Has Been Signed on 07/12/2023 08:04 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:SACRED HEART SENIOR CAREFACILITY NUMBER:
306005755
ADMINISTRATOR:ALDIANO, ANNA LIZAFACILITY TYPE:
740
ADDRESS:25602 WILLOW BENDTELEPHONE:
(949) 600-7009
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 5DATE:
07/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Marebith NeryTIME COMPLETED:
03:30 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) Lydia Martinez made an unannounced visit to the facility for the purpose of conducting a Case Management - Incident visit to review a recent Resident's death reported. LPA was greeted and granted entry into the facility by staff Ditas Almendrala. Administrator Marebith Nery arrived shortly after and explained the nature of the visit.

During today’s visit LPA interviewed staff, toured the physical plant of the facility, reviewed client file, and obtained copies of pertinent documents. Resident (R1) had finished eating dinner in R1's bedroom. R1's dinner was a grilled cheese sandwich and a cup of fresh strawberries. R1 left about a quarter of the sandwich and ate about 2 strawberries. Staff 1 (S1) asked R1 if R1 wanted ice-cream and R1 said no and only asked for ice cold water. Per S1, left to get R1's water and evening medication and returned 10-15 minutes later. S1 noted R1 gasping for air and immediately got AD who was in the staff room. AD called 911 and 911 gave AD instructions on performing CPR. Orange County Fire Authority (OCFA) arrived about 5 minutes later. OCFA performed chest compressions using compression machine on R1's chest for about 15 minutes. R1 was pronounced deceased at about 6:45 PM. Paramedics called R1's wife to inform her of the incident. Orange County Sheriff's arrived and spoke to S1. AD stated paramedics informed her there was no food lodged in R1's throat but did not give AD a cause of death. R1's remains have been released to Mortuary as there would be no autopsy done. Per physician report dated 7/28/2022, R1 was diagnosed with Fall/Debility and Chronic Compression Fx. R1 was being seen once a month by House Call Doctors and last contact was 06/17/2023.

Facility to obtain a copy of the Death Certificate and forward to LPA Martinez upon receipt.

No deficiencies were cited during this visit. Exit interview conducted and a copy of this report will be sent to email on file.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1