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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603510
Report Date: 12/09/2021
Date Signed: 12/09/2021 03:40:34 PM

Document Has Been Signed on 12/09/2021 03:40 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:AQUINO'S QUALITY HOMECARE NO. 2FACILITY NUMBER:
374603510
ADMINISTRATOR:BERNARDO AQUINOFACILITY TYPE:
735
ADDRESS:1839 ITHACA STREETTELEPHONE:
(619) 272-4223
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY: 6CENSUS: 5DATE:
12/09/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:TIME COMPLETED:
04:11 PM
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Licensing Program Analyst (LPA) Kennedy conducted a case management visit to complete a review regarding a self-reported death of Client 1 (C1) (See LIC 811 for confidential names) received by CCL on 12-8-21. LPA met with Emma Manalo, House Manager and discussed the purpose of the visit.

LPA reviewed C1's facility file toured the facility, interacted with clients and interviewed staff about events leading up to the death. C1 resided at the facility since 11-17-17. On 12-3-21 C1 complained of abdominal pain and was vomiting. 911 was called and C1 was sent to the hospital. C1 was transferred to another hospital on 12-4-21 where she became unresponsive and given a diagnosis and a prognosis of eminent death. The family made end of life decisions and C1 passed away on 12-8-21. The death of C1's was relatively sudden with only five days between onset of symptoms, hospitalization and death, however the death was expected.

No deficiencies were cited during the visit.

An exit interview was conducted with Emma Manalo, House Manager. A copy of this report was provided to the administrator via email. An electronic response confirms the documents were received. Licensee Rights (LIC9058 01/2016) were left at the facility.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Anna Kennedy
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
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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