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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202509
Report Date: 11/02/2023
Date Signed: 11/02/2023 04:13:37 PM


Document Has Been Signed on 11/02/2023 04:13 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:VILA MONTEFACILITY NUMBER:
435202509
ADMINISTRATOR:NICHOLAS INNEHFACILITY TYPE:
740
ADDRESS:17090 PEAK AVENUETELEPHONE:
(408) 500-2693
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:28CENSUS: 25DATE:
11/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Nicholas InnehTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived to the facility unannounced to conduct a case management – incident visit regarding an incident that occurred at the facility on 10/12/2023. LPA met with Administrator, Nicholas Inneh.

On 10/26/2023, LPA Dolores was made aware of a resident (R1) who passed away.

On 10/12/2023, staff noticed that R1 was choking on food and immediately called 911 and began CPR and First Aid (Heimlich Maneuvers). R1 then lost consciousness and staff began chest compressions until EMT arrived. R1 was transported to the hospital and pronounced deceased on 10/13/2023.

Based on interview and review of R1’s records, R1 did not have a special diet. For dinner that night, the residents were served chicken burritos. ADM states the resident did not have any issues with swallowing food or medical conditions regarding his/her throat. ADM is not aware of any history of R1 choking on food. After the incident, the ADM immediately informed R1's case manager, conservators, and physician. The staff who provided CPR has an active CPR/First Aid Certification. ADM stated on the morning of 10/13/2023, R1's case manager arrived to the facility and informed the facility staff that R1 had passed away at the hospital.

LPA requested for R1’s death certificate.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Nicholas Inneh and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023
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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