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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004350
Report Date: 09/25/2024
Date Signed: 09/25/2024 12:14:23 PM

Document Has Been Signed on 09/25/2024 12:14 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:HENDERSON HOUSEFACILITY NUMBER:
347004350
ADMINISTRATOR/
DIRECTOR:		EDMON ORIANFACILITY TYPE:
735
ADDRESS:3909 HENDERSON WAYTELEPHONE:
(916) 550-1473
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 4CENSUS: 3DATE:
09/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:19 AM
MET WITH:Edmon OrianTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding a death report LPA received for C1 on 09/23/2024. LPA met with Administrator and explained the purpose of the visit.

Death report revealed C1 was awakened by staff around midnight on 09/21/2024, which S1 then observed C1 to be weak and unable to lift themselves onto the wheelchair. C1 then slid onto the floor with S1's guidance which C1 laid down to rest. Death report stated S1 then observed C1 to show signs of shortness of breath. S1 contacted 911 immediately and then notified Administrator. S1 stayed with C1 until emergency medical services arrived shortly afterwards. Emergency medical services was observed to be checking C1's vitals and then performed cardiopulmonary resuscitation. Emergency medical services then informed facility staff C1 passed away and the coroner office will be coming to the facility to retrieve C1.

LPA and Administrator discussed that C1's time of death was unknown as emergency medical services did not provide facility with the following information. Administrator stated C1 went to day program day prior to the incident, and no concerns were reported to facility. Administrator stated C1 returned to the facility in the afternoon and was observed to be "fine and normal" and finished all his dinner.

LPA obtained a copy of C1's LIC 602, on-going notes for month of August 2024 and September 2024, Needs and Service Plan for 2024, primary care physician visit notes for visit of 09/17/2024.

At this time, the incident remains under review by the Department until further notice.

Exit interview and a copy of the report was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
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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