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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002454
Report Date: 04/12/2022
Date Signed: 04/13/2022 02:26:26 PM

Document Has Been Signed on 04/13/2022 02:26 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:JOAQUIN HOMEFACILITY NUMBER:
455002454
ADMINISTRATOR:CAMPBELL, JENNIFERFACILITY TYPE:
735
ADDRESS:662 JOAQUIN AVENUETELEPHONE:
(530) 244-9025
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 4CENSUS: 2DATE:
04/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:32 PM
MET WITH:(Admin) Cameron OlsonTIME COMPLETED:
01:45 PM
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On 04.12.22 Licensing Program Analyst (LPA) Misty Valencia arrived at the facility unannounced to conduct a complaint investigation. LPA met with Administrator (Admin) Cameron Olson and explained the purpose of the visit. Prior to initiating the complaint investigation LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. In addition LPA was screened by administrator. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask, additionally LPA was screen at the front door.

The facility notified CCL on 02/22/22 that C1 had passed away. C1 was found in her room at approximately 920 am curled up in a ball by the Admin and apparently had a bowel movement accident, which C1 has never had before. Admin tried to get her to stretch her legs and take her medications. Admin noticed that C1 looked tired, asked her if she was okay and if she needed Emergency Services (EMS). C1 explained to Admin that her legs were hurting, but she did not want EMS C1 then started gargling and trying to spit out her medications. Admin decided to contact EMS. While waiting for EMS, C1 became unresponsive and Admin had to administer CPR. Admin completed two (2) rounds of CPR and contacted EMS again to let them know CPR was needed and he was currently conducting. Other staff showed up when EMS showed up. Staff took the other two (2) clients out to lunch so they did not have to see what was going on. Admin continued to do CPR until EMS took over, then Paramedics took over and continued CPR. Approximately fifteen (15) minutes of them conducting CPR, C1 never took another breath. EMS called time of death.

During today's call, LPA requested the following documents for C1's: Admission Agreement, Care Plan, Charting Notes and LIC602. No deficiencies are being cited as a result of today's case management.
Exit interview conducted and copy of report to be sent to admin via email
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Misty Valencia
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
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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