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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 310302384
Report Date: 09/02/2020
Date Signed: 09/02/2020 12:03:41 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR., STE 270
SACRAMENTO, CA 95833
FACILITY NAME:EDGEWOOD GUEST HOMEFACILITY NUMBER:
310302384
ADMINISTRATOR:ANDRADA, T. AND R.FACILITY TYPE:
740
ADDRESS:1361 MARTIN DRIVETELEPHONE:
(530) 885-9613
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:15CENSUS: 13DATE:
09/02/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tito Andrada, Jr.TIME COMPLETED:
11:00 AM
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On 9/2/2020 LPA Tryon contacted the facility regarding a Death Report dated 9/1/2020. LPA spoke with Administrator Tito Andrada, Jr.

LPA received a report that resident R1 had passed on 9/1/2020. LPA spoke with Mr. Andrada to learn further details. As per report and speaking with Mr. Andrada, R1 had a normal day on Monday, 8/31/2020. He was active, participated in normal activities, was excited about the upcoming Labor Day holiday, had participated in making holiday decorations. Nothing out of the ordinary was noted. R1's appetite was good. He had not had any unusual illness, complaints, etc. R1 followed normal routine on Monday, took his evening medications and went to bef shortly after 7:30 p.m. Monday evening. Staff checkedf in on him at about 11:30 p.m. and found him sleeping. In the morning R1 did not get up as early as his habit. When staff checked in his room, they found him on the floor next to his bed in fetal position, unresponsive and obviously had passed some time before.. 911 was called. Staff was not able to get R1 in a position to attempt CPR. Paramedics arrived, assessed situation. Coroner was contacted, arrived and stated that death was from natural causes, most likely cardiac.

At this time, it appears that the home noted nothing out of the ordinary to cause concern or alarm on Monday, R1 followed usual routine, and went to bed normally. It appears that upon discovering R1 staff attempted to assist to the best of their ability and contacted 911 right away. Administrator said the Coroner stated resident passed due to natural causes. LPA requested copy of resident's latest Physician Report, Cardiac Appointment, IPP, Coroner's Report/death report if available.

No deficiencies are cited at this time. Exit interview held with Admionistrator.

Due to COVID-19 issues, this visit was done virtually. LPA will forward this report to Mr. Andrada for signature. He will send a copy of signed document back to LPA. Hard copy will be maintained in facility file.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2020
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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