430703824-2-23-2024-26-AS-KHOS-D4DHWT-20240416063401

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430703824
Report Date: 02/23/2024
Date Signed: 02/23/2024 10:20:00 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/07/2023 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20231107101351

FACILITY NAME:	PACE - MEADOWS		FACILITY NUMBER:	430703824
ADMINISTRATOR:	NAWARD HERNANDEZ		FACILITY TYPE:	735
ADDRESS:	862 HOLLENBECK AVENUE		TELEPHONE:	(408) 835-5503
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY:	6	CENSUS: 6	DATE:	02/23/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Naward Hernandez		TIME COMPLETED:	10:25 AM

ALLEGATION(S):

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Questionable death
Staff did not follow a client's medical orders

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding of the above allegations. LPA met with Administrator, Naward Hernandez.

On 11/07/2023, the Department received a complaint alleging facility staff did not follow a client’s medical orders and questionable death. On 11/08/2023, the initial complaint investigation was conducted.

The following documents were obtained for this investigation to include the facility menu, staff roster, resident (R1)’s physician’s report, appraisal/needs and services plan, quarterly IPP report, behavioral report, and medical records. SEE LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20231107101351

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PACE - MEADOWS	FACILITY NUMBER: 430703824
	VISIT DATE: 02/23/2024

NARRATIVE

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On 09/13/2023, resident (R1) was transported to the hospital after choking on a piece of pastry. During the incident, 3 staff members were present. 2 out of 3 staff members were present serving R1 and other residents with their breakfast. Based on staff interviews, as staff (S1) was preparing the food for R1, another resident (R2) gave R1 a pastry and R1 started eating it. R1 stood up and S1 noticed R1 was having a hard time breathing. S1 called S2 for help and staff (S2) then provided first aid while S1 contacted Emergency Medical Services (EMS). During the ambulance ride, R1 began to go into cardiac arrest. Upon arriving to the hospital, R1’s developed severe medical conditions. On 09/26/2023, R1 passed away at the hospital with an official cause of death being cardiac arrest.

The review of the video footage from the incident corroborated the staff members statements.

Based on staff interview, 4 out of 4 staff members stated none of the residents to include R1, had any food restrictions and history of choking on food.

The review of R1’s records shows that R1 did not have a special diet or food restrictions. R1 was able to feel self.

The Department has investigated the above allegations. Based on interview, record review, and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Naward Hernandez and a copy of the report was provided.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC9099 (FAS) - (06/04)

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