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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005824
Report Date: 07/06/2022
Date Signed: 07/06/2022 12:26:43 PM

Document Has Been Signed on 07/06/2022 12:26 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:LINDEN GROVE ADULT RESIDENTIALFACILITY NUMBER:
397005824
ADMINISTRATOR:CAMPBELL, MARICA Z.FACILITY TYPE:
735
ADDRESS:21373 EASTERN HEIGHTS RDTELEPHONE:
(209) 430-8869
CITY:LINDENSTATE: CAZIP CODE:
95236
CAPACITY: 6CENSUS: 4DATE:
07/06/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Ashley Struther, House ManagerTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) R. Campbell and LPA T. White conducted an unannounced Case Management visit on this date and met with House Manager, Ashley Struther. The case management visit pertains to an incident report and a death report submitted to CCLD on 06/25/2022.

Based on incident report, on June 21st, 2022, Client #1 (C1) had two sudden bowel movements in the living area of the facility. When staff attempted to help him shower, he began to expel yellow fluid from his nose and mouth. After C1 became unresponsive, staff-initiated CPR until emergency responders arrived.

Based on Staff #1 (S1) interview, C1 had been away from the facility for one month. C1 had first been to St. Joseph’s Hospital for two bowel reconstruction surgeries and later went to a Skilled Nursing Facility (SNF) for recovery. C1 was on a low sodium diet of pureed food and ensure on the day of his death. Documentation shows C1 had a history of issues with bowel movements. C1 passed within 24 hours of returning to the facility. Per S1's observation, C1 was not ready to return home. While in the hospital, C1 was weak and those who sat with him in the hospital stated C1 did not want to drink water and his general behavior was different from baseline.

Based on documentation, C1 was admitted to the hospital on 06/13/2022 and discharged from the hospital on 06/20/2022. C1 passed on 06/21/2022. C1 had a history of irregular digestion and bowel movements. Based on information provided, LPA may decide to visit at a later date. No deficiencies cited at this time. Exit interview conducted with House Manager and a copy of report given.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2022
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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