397002682-10-26-2023-27-AS-AJON-CWYNH8-20231026102818

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397002682
Report Date: 10/09/2023
Date Signed: 10/26/2023 10:28:22 AM

Document Has Been Signed on 10/26/2023 10:28 AM - 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	SUNNY PLACE OF STOCKTON		FACILITY NUMBER:	397002682
ADMINISTRATOR:	EXPECTACIO VIERRA		FACILITY TYPE:	740
ADDRESS:	807 WEST SWAIN ROAD		TELEPHONE:	(209) 956-8677
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95207
CAPACITY:	18	CENSUS: 11	DATE:	10/09/2023
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	EXPECTACIO VIERRA		TIME COMPLETED:	01:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Albert Johnson met with Expectacio Vierra for conducted an unannounced case management visit to issue civil penalty per Health and Safety Code § 1569.49(f). On October 27, 2022, the Department initiated a complaint investigation alleging that the facility staff did not follow the resident’s (R1) care plan and failed to provide proper care to R1. On January 17, 2023, the Department concluded the complaint investigation and substantiated both allegations. The licensee was cited for violating California Code of Regulations (CCR), Title 22, Division 6, § 87464(f)(1) Basic Services and CCR-, Title 22, Division 6, §87405 (h)(5) Administrator - Qualifications and Duties. The investigation revealed that on March 15, 2022, the facility staff reported R1 choked on a hot dog and fell onto the floor. There are conflicting statements whether staff did or did not perform the Heimlich Maneuver. Staff contacted 9-1-1 and started to perform cardiopulmonary resuscitation for seven minutes prior to arrival of the local fire jurisdiction. According to documentation from the fire department, R1 was found unresponsive, pulseless, and apneic upon their arrival. Fire department (FD) staff performed CPR, and then completed a direct laryngoscopy. Continued

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SUNNY PLACE OF STOCKTON	FACILITY NUMBER: 397002682
	VISIT DATE: 10/09/2023

NARRATIVE

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They pulled out a 1.5-inch piece of a hot dog that caused a full foreign body airway obstruction (FBAO). The FD staff continued CPR which resulted in return of spontaneous circulation.

At approximately 4:03 p.m., the paramedics arrived and found R1 lying supine on the ground with facility staff and the fire department present. R1 was still apneic, so R1 was intubated, revived, and subsequently transferred to the hospital. Review of medical records indicated that R1 was revived twice, placed on ventilator for two days, and passed away five days after R1 was taken off from the ventilator.

Based on review of R1’s facility record, a memorandum was written and signed by the licensee on February 23, 2022, which states, "Diet: Soft diet only due to missing front teeth. Regular Soft Diet: chopped meat!" This Memorandum indicated R1 was assessed and evaluated based upon R1’s family and the administrator assessment. It was sent to all care staff and marked as urgent.

The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation.” Due to the negligence of the licensee in providing a soft diet, R1 choked on a 1.5-inch piece of hot dog and sustained a FBAO. R1 passed away 8 days after hospitalization.

Today 10/9/2023 the Department will be issuing a civil penalty per Health and Safety Code 1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of $10,000.00. However, since an immediate civil penalty was issued on January 17, 2023, the amount of the civil penalty issued today will be adjusted to $9,500.00. A copy of the LIC 421D was given and originals were signed.

Exit interview conducted. A copy of the report issued. Appeal rights provided. Expectacio Vierra signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

LIC809 (FAS) - (06/04)

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