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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005503
Report Date: 10/18/2023
Date Signed: 10/18/2023 03:31:22 PM

Document Has Been Signed on 10/18/2023 03:31 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 #2FACILITY NUMBER:
397005503
ADMINISTRATOR:MARYANN PATACSILFACILITY TYPE:
735
ADDRESS:335 PRADO WAYTELEPHONE:
(209) 477-4915
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 6CENSUS: 4DATE:
10/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Maryann MasayaTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Michael Bilger arrived on October 18th, 2023 for an unannounced inspection to follow up on an investigation related to an incident report and death report. LPA met with Administrator Maryann Masaya and explained the purpose of the visit.

On May 18, 2023, the Department concluded an investigation into a questionable death resulting from a lack of care and supervision. The licensee was cited for a violation of California Code of Regulations (CCR) 80078(a), Care and Supervision on May 30, 2023.

The investigation revealed that on January 16, 2023, Staff (S1) passed out the breakfast plates. The resident (R1) started coughing while continuing to eat. S1 asked if R1 was okay and R1 nodded their head. Approximately two minutes later, R1’s coughing worsened, and their 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. Paramedic crews used forceps to remove a “large amount of food” in multiple pieces. Paramedics were unable to intubate due to the amount of hot dogs and waffles obstructing R1’s airway. R1 was transported to the local hospital. Emergency room doctors were successful to intubate on the fifth time. {Cont. on 809D}
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: 10/18/2023
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The attending physician (P1) wrote “intubation was complicated due to significant amount of food particles” which were removed using suction and Magill forceps. R1 passed away on January 16, 2023, at 5:20 p.m.

Staff (S2) confirmed they cooked breakfast that morning. S2 prepared three individual pre-portioned plates of an Eggo waffle, Vienna sausages, and fruit. S2 demonstrated how they cut up the food by preparing a plate 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 one and a half pieces. S2 said they prepared all the client’s plates the same with the exception of one client who was on a pureed diet.

S1 served food each morning including the day of the incident. S1 reported that all three plates were prepared the same. S1 did not recall which meat was served on the day of the incident but did recall that the waffle on R1’s plate was whole.

During the investigation, S1 denied R1 had difficulty swallowing or required a special diet. S2 and the licensee confirmed that R1 had a history of difficulty swallowing and required food be cut into “bite size” pieces. Licensee and S2 were also able to refer the investigator to a list of clients’ dietary needs which was posted on the refrigerator. R1’s type of diet posted was “regular; fed chopped portions due to choking per family.” R1’s Physician’s Report dated September 24, 2022, stated R1 can feed themself but required a special diet of food “chopped to bite sizes to prevent choking.”

{Cont. on 809C}
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 10/18/2023
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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 coroner’s office determined the cause of death to be anoxic brain injury due to asphyxia and food bolus obstruction of the upper airway. Another significant condition was noted as congenital neuro-debilitated state with seizure.

At the time of the case management visit on May 30, 2023, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code section 1548.

The Department has concluded an analysis and has determined that a civil penalty is warranted for the death of R1. This is evidenced by the licensee not ensuring that staff were adequately informed of the appropriate measures needed including texture modification of food and supervision needed to minimize the risk of R1 choking which resulted in the death of R1.

Today October 18th, 2023, the Department will be issuing a civil penalty per Health and Safety Code section 1548 for a violation that the department determined resulted in the death of a resident at an adult residential facility in the amount of $15,000. However, since an immediate civil penalty of $500 was previously issued on May 30, 2023, the amount of the civil penalty issued today will be $14,500.

{Cont. on 809C}
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 10/18/2023
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A copy of the LIC 421D was given to Maryann Masaya and originals were signed.

Exit interview conducted. A copy of the report issued. Appeal Rights provided. Maryann Masaya signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4