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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294256
Report Date: 08/11/2020
Date Signed: 08/11/2020 01:35:19 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:EASTRIDGE RESIDENTIAL CARE HOMEFACILITY NUMBER:
435294256
ADMINISTRATOR:MARY ROSE BAQUIRANFACILITY TYPE:
740
ADDRESS:2690 KEPPLER DRIVETELEPHONE:
(408) 799-0502
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY:6CENSUS: 4DATE:
08/11/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Mary Rose BaquiranTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Gladys Kuizon conducted a Case Management tele-visit today and met with Administrator, Mary Rose Baquiran (S1). Due to COVID-19 preventive measures, facility visits have been suspended.

The purpose of this case management was to obtain more information on the events surrounding resident (R1)'s death. The Department received an LIC 624A Death Report from the facility stating that R1 was found unresponsive in the facility on August 10, 2020. The cause of death was unknown at time of report.

S1 stated that R1 was discharged from the hospital on August 7, 2020. There were adjustments to R1's medications and an order for home health evaluation. On August 9, 2020, R1 was seen and evaluated by home health nurse at the facility. On August 10, 2020, R1 was found unresponsive at approximately 4:30 AM. 911 was called and R1 was pronounced dead at approximately 5:07 AM.

S1 stated that facility staff checked on R1 at approximately midnight and 3:30 AM. And then again at approximately 4:30 AM.

R1 was on hospice 2 years ago and was discharged from hospice in December 2019. There have been discussions about re-admitting R1 to hospice again due to loss of appetite and refusal of medications. R1's responsible party in involved in R1's care.

R1's death report has not yet been released and official cause of death is still to be determined. S1 will inform Community Care Licensing and forward a copy of R1's death certificate once available.

-END OF REPORT-
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2020
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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