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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317000496
Report Date: 01/04/2024
Date Signed: 01/04/2024 12:41:52 PM

Document Has Been Signed on 01/04/2024 12:41 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:C. SEISA HOUSE-STODDARDFACILITY NUMBER:
317000496
ADMINISTRATOR:SEISA, CUSTODIO A.FACILITY TYPE:
735
ADDRESS:317 STODDARD WAYTELEPHONE:
(530) 889-0737
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 6CENSUS: DATE:
01/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jenifer Balmeo, Staff; Joel Seisa, LIcensee by phoneTIME COMPLETED:
12:30 PM
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On 1/4/2024 LPA Tryon visited the facility to follow up on the recent death of a resident. LPA was greeted by staff Jenifer, and spoke with licensee Joel Seisa by phone.
Mr. Seisa said that the resident had been ill on December 1 and taken to the hospital, where he stayed for a week. The resident was found to have pneumonia. He was discharged after a week and sent home. Resident received home health nurse and dietician at home after discharge. On 1/2/24 staff found the resident appearing to not be doing well. Licensee checked on him and he was breathing, called 911. When asked to check again the resident did not appear to be breathing. Licensee started chest compressions following 911 instructions until paramedics arrived and took over. They continued the attempt for about a half hour, and then stopped and he was pronounced dead.

The resident was taken by the mortuary. As per family, no autopsy was performed.

It appears that the facility had followed up on medical care along with the resident's family as per direction. The resident was receiving home health services as ordered. When resident was discovered staff took immediate action, contacted 911 and followed instructions. It appears the home followed through appropriately.

LPA has asked the facility to provide the medical records that they have. Mr. Seisa said that the family was in charge of his medical care, and the medical provider had not agreed to give records to the home, as the family was working with them. Facility agreed to provide items they do have.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024
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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