366424311-5-10-2023-56-AS-VCHN-CRPTB3-20230510143427

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366424311
Report Date: 05/10/2023
Date Signed: 05/10/2023 02:34:32 PM

Document Has Been Signed on 05/10/2023 02:34 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	KAISER SPECIALIZED RESIDENTIAL MERLOT		FACILITY NUMBER:	366424311
ADMINISTRATOR:	MILES, WILTON		FACILITY TYPE:	735
ADDRESS:	21295 MERLOT LN		TELEPHONE:	(760) 240-9976
CITY:	APPLE VALLEY	STATE: CA	ZIP CODE:	92307
CAPACITY: 4		CENSUS: 3	DATE:	05/10/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Staff Juanita Powell		TIME COMPLETED:	02:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Victoria Chitgian arrived to the facility to gather documentation related to an adult death of client #1 (R1). LPA met with Administrator Star Pillman, Staff member Juanita Powell and interviewed Staff Erin Linton.

Client was diagnosed with Autism, Profound mental retardation, bipolar disorder. Staff 1 explained that Client 1 was non-verbal. On 3/31/2023, Client displayed difficulty "catching her breath" during dinner at 5pm. Earlier it was noted that client did not drink her favorite "chocolate milk". Clients food was pureed. Client was observed gasping for air. After three (3) bites, client was displaying difficulty swallowing, however pulled food forward to continue eating her dinner at around 5:30pm. Client recovered and acting "back to normal". At 7pm, Medications were being passed. Staff 1 observed Client may have aspirated on the water given during medication pass. Client sounded "raspy", and not her normal "grunting sounds" were observed. Staff 1 made the decision to call paramedics at 7:45pm. Per Staff 1, Paramedics arrived 10 minutes later, at about 8pm. Client had a bowel movement and displayed vomiting sitting straight up in her chair. Staff held the client during the paramedic intervention due to clients hand movement. Client was "fighting off" the paramedics during blood pressure check and the "blood oxygen level" exam. Staff 1 explained Client would often not want medical personnel and doctors to examine her. Paramedics assessed her and transported to the closest hospital; St. Mary's Hospital.

Earlier that month on 03/11/2023, Client was diagnosed with pneumonia on 3/11/2023 at Providence St. Mary Hospital. Per Medication record review, Client 1 was taking her regularly prescribed medication.

LPA obtained the following documentation during today's visit: Medication Administration Record (MAR) Special incident report, Client rights form, admission's agreement, client's physician's report, IRC IPP, Staff CPR card weight log, prescribed medications, medical report, centrally stored medication record, and death report. Administrator will provide LPA with additional CPR certificates of staff on duty during the time of incident. An exit interview was conducted and a copy of this report was provided to Staff Juanita Powell.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

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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