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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202665
Report Date: 04/06/2023
Date Signed: 04/06/2023 02:38:22 PM


Document Has Been Signed on 04/06/2023 02:38 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:LOMA CLARA SENIOR LIVINGFACILITY NUMBER:
435202665
ADMINISTRATOR:JAIRUS CABUENAFACILITY TYPE:
740
ADDRESS:16515 BUTTERFIELD BLVDTELEPHONE:
(669) 258-3500
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:89CENSUS: 63DATE:
04/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Jett CabuenaTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – incident visit based on an incident report and death report received for resident (R1). LPA met with Executive Director (ED), Jett Cabuena.

On 04/05/2023, the Department received an incident report and death report for resident (R1). On 03/29/2023, R1 was eating breakfast in the dining room when it was observed R1 was choking on food. Staff immediately administered the Heimlich Maneuver and called 911. EMS arrived on scene between 5-10 minutes from the initial call. EMS arrived and took over care for the resident. R1 expired at the facility.

During visit, LPA interviewed the ED. Based on interview, ED confirmed the details of the report and stated R1 was given eggs, potatoes and sausages for breakfast. ED stated R1 does not have history of choking on food. LPA obtained records to include R1's physician's report, needs and services plan, hospice records, POLST, DNR, special diet board of memory care residents, and staff (S1) first aid certification. Based on record review, R1 was given a regular diet. R1 was able to feed self with no assistance required. R1's medical records did not indicate R1 required a special diet (ex: pureed or mechanical soft foods).

The facility is pending the coroner's report. The facility will forward the Department R1's coroner's report and death certificate once obtained.

No deficiencies are cited per California Code of Regulations, Title 22.

This report was reviewed with Executive Director, Jett Cabuena 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: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023
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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