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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005719
Report Date: 06/03/2024
Date Signed: 06/03/2024 11:06:19 AM

Document Has Been Signed on 06/03/2024 11:06 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DIGNA'S CARE HOME #1FACILITY NUMBER:
397005719
ADMINISTRATOR/
DIRECTOR:		CABRERA, DIGNAFACILITY TYPE:
735
ADDRESS:2955 CHRISTINA AVETELEPHONE:
(209) 598-7588
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 6CENSUS: 5DATE:
06/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Digna C.TIME VISIT/
INSPECTION COMPLETED:
11:12 AM
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On 6/03/24, Licensing Program Analyst (LPA) Albert Johnson made an unannounced case management visit. The incident on 5/21/2024 was reported to the department. LPA spoke with Digna Cabrera, Administrator.

LPA reviewed R1's incident report, R1 passed away unexpectedly. The department has requested copies of R1's file information.

R1 passed away on May 21, 2024, at 6:41 AM. Cause of Death according to the interim patient report from the AMR is Cardiac Arrest.

R1 does not have any family or relatives that the facility is in contact with to notify them of R1's death.


No deficiencies were cited during today's visit.


Exit interview conducted
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 06/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2024
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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