397005503-5-30-2023-27-AS-MJEN-CSBURS-20230530154914

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397005503
Report Date: 05/30/2023
Date Signed: 05/30/2023 03:49:22 PM

Document Has Been Signed on 05/30/2023 03:49 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	MARYANN PATACSIL'S CARE HOME #2		FACILITY NUMBER:	397005503
ADMINISTRATOR:	MARYANN PATACSIL		FACILITY TYPE:	735
ADDRESS:	335 PRADO WAY		TELEPHONE:	(209) 477-4915
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95207
CAPACITY: 6		CENSUS: 3	DATE:	05/30/2023
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Maryann Masaya		TIME COMPLETED:	04:00 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	On 5/30/2023, Licensing Program Analysts Maja Jensen and Jennifer Fain arrived unannounced to deliver findings related to an investigation that was conducted by the Department stemming from an incident report received related to a client death. LPA's Jensen and Fain met with Licensee and explained the purpose of today's visit. This investigation was conducted as a result a client death on 1/16/23. During the course of this investigation, the Department conducted interviews with staff, clients and a client family member. The Department also reviewed records including but not limited to facility records, medical records, and a coroner’s report. It was determined that on 1/16/2023 Staff 1 (S1) passed out the breakfast plates for the residents. Resident 1 (R1) was eating his food “fast” with his hands. R1 started coughing while continuing to eat. S1 asked if R1 was okay and R1 nodded his head. Approximately two minutes later, R1’s coughing worsened and his face was turning blue. S1 called 911 and started chest compressions. S1 was able to remove some chewed up food from R1’s throat before paramedics arrived, but R1 was still unconscious. R1’s medical records documented R1 was cyanotic, pulseless, and not breathing when paramedics arrived. Paramedic crews used forceps to remove a “large amount of food” in multiple pieces, approximately "half a hot dog". Paramedics were unable to intubate due to the amount of hot dogs and waffles obstructing his airway. R1 was transported to a medical center. Emergency room doctors were successful to intubate on the fifth try. An attending physician wrote “intubation was complicated due to significant amount of food particles” which were removed using suction and Magill forceps. R1’s responsible party (RP) wished to proceed with comfort care only and R1 was extubated. R1 passed away on 1/16/2023, at 1720 hours. Continued on LIC 809C....

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

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: MARYANN PATACSIL'S CARE HOME #2	FACILITY NUMBER: 397005503
	VISIT DATE: 05/30/2023

NARRATIVE

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Staff 2 (S2) confirmed she cooked breakfast that morning. She prepared three individual pre-portioned
plates of an Eggo waffle, Vienna sausages, and fruit. During the course of an interview, S2 demonstrated how she cut up the food by preparing a plate for a Department Investigator and confirmed the portions were cut similarly the day R1 choked. The toasted waffle was cut once in half and the sausages were cut into approximately 1 ½ inch pieces. S2 said she prepared all the client’s plates the same with the exception of one client that was on a pureed diet. S1 did not recall which meat was served and stated the waffle on R1’s plate was whole. The Department Investigator asked how S1 knew which plate to give to R1. S1 replied all three plates were prepared the same way.

S1 said R1 did not like to have his food cut up. She denied R1 had difficulty swallowing or required a special diet. However, S2 and Licensee Maryann Masaya stated R1 had a history of difficulty swallowing and required food be cut into “bite size” pieces. Maryann Masaya and S2 stated a list of clients’ dietary needs was posted on the refrigerator. Adam’s type of diet was “regular; red chopped portions due to choking per family.” The RP confirmed staff were aware R1 had difficulty swallowing. Additionally, R1’s Physician’s Report dated 9/24/2022 stated R1 can feed himself but required a special diet of food “chopped to bite sizes to prevent choking.” Multiple staff stated R1 did not have any prior choking episodes but regularly consumed food fast and had to be reminded to slow down.

The County Coroner’s Office determined the cause of death to be anoxic brain injury due to
asphyxia and food bolus obstruction of the upper airway. Other significant condition was noted as congenital neuro-debilitated state with seizure. The manner of death was an accident. As a result of the investigation it was determined that Facility staff’s neglect and/or lack of care or supervision resulted in the questionable death of R1.

The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations/Health and Safety Codes. Failure to correct the deficiency may result in additional civil penalties. At the time of this case management visit, the issuance of further Civil Penalties is still being determined and the licensee was informed that an additional civil penalty and/or administrative action might be assessed based on Health and Safety Code Section 1548(e). An exit interview was conducted with Maryann Masaya and a copy of this report was and Appeal rights were provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/30/2023 03:49 PM - It Cannot Be Edited

Created By: Maja Jensen On 05/30/2023 at 02:16 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: MARYANN PATACSIL'S CARE HOME #2	FACILITY NUMBER: 397005503
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/30/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 05/31/2023 Section Cited CCR 80078(a)	1 2 3 4 5 6 7	Responsibility for Providing Care and Supervision The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Licensee agrees to conduct an in-service training on food preparation and following physician report directives. A signed attestation verifying training was completed will be emailed to maja.jensen@dss.ca.gov
	8 9 10 11 12 13 14	Based on a review of facility records, medical records, R1 required chopped food and was served food not prepared in such a manner so as to avoid presenting a choking hazard which resulted in the resident's death. This poses an immediate risk to the health, safety and personal rights of residents in care	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Liza King

LICENSING EVALUATOR NAME:

Maja Jensen

LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC809 (FAS) - (06/04)

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