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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802130
Report Date: 07/09/2021
Date Signed: 07/09/2021 03:49:19 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:DOCTOR'S RESIDENTIAL CARE FACILITYFACILITY NUMBER:
425802130
ADMINISTRATOR:GILL, NATASHAFACILITY TYPE:
735
ADDRESS:925 W. CLARENCE CT.TELEPHONE:
(805) 623-5490
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY:4CENSUS: 3DATE:
07/09/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH:Natasha Gill, AdministratorTIME COMPLETED:
10:46 AM
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Licensing Program Analyst (LPA) Chavez conducted a Case Management - Incident visit in response to a phone call from the administrator stating the facility had a death of Resident #1 (R1). LPA explained the reason for the visit.

LPA interviewed Administrator and Staff #1 (S1). S1 and Staff #2 (S2) were at the facility at the time of the incident. Staff #3 (S3), who was at the facility during the incident, was not present during LPA's visit.

History of the incident is as follows: On 7/07/21 at 1:43 pm, LPA Chavez had a voicemail message from Administrator Natasha Gill and was unable to return her call. On 7/08/21 at 8:03 am, Administrator called and spoke with LPA Chavez to inform that a client, Michael Garfunkel, had passed away on 7/07/21 due to choking on a quesadilla at lunch. Administrator said client had two (2) staff feeding him which is what was needed at all times. Administrator states that if client did not have assistance with meals, he would consume the entire plate in one bite. Administrator said that client was on a small bite diet. Staff Nathaly Chavez and Gerardo Zul assisted client with lunch on 7/07/21 beginning at 12:30 pm and when client began to choke at 12:45 pm, Gerardo performed the Heimlich Maneuver. Administrator states client was not stable standing so Nataly and Gerardo laid client down and Nataly called 9-1-1 at 12:48 pm while Gerardo began CPR. AMR Paramedics arrived at 12:56 pm and took over CPR. Santa Barbara City Police arrived at approximately 1:20 pm, ant then at approximately 1:30 -1:35 pm Santa Barbara County Sheriff J. Gutierrez arrived. Client was pronounced dead at 1:15 pm by AMR paramedics. Administrator states that client drank a full glass of water with his quesadilla. At 3:00 pm, client’s body was transported to Dudley Hoffman Mortuary.

The facility notified Department of Developmental Services (DDS), Tri-Counties Regional Center (TCRC), the resident’s responsible party of the death, and Long-Term Care Ombudsman.

Exit interview conducted and a copy of report emailed to administrator to returned signed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021
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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