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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800978
Report Date: 08/23/2022
Date Signed: 08/23/2022 02:54:34 PM


Document Has Been Signed on 08/23/2022 02:54 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:UNIVERSITY VILLAGE THOUSAND OAKSFACILITY NUMBER:
565800978
ADMINISTRATOR:DMITRY ESTRINFACILITY TYPE:
741
ADDRESS:3415 CAMPUS DRIVETELEPHONE:
(805) 241-3000
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:514CENSUS: 473DATE:
08/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Dmitry EstrinTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced case management visit today. The purpose of this visit is conclude the investigation regarding the incident occurred on 03/21/2022.

On 03/22/2022, the Department received an unusual incident report (IR) regarding Resident #1 (R1). On 03/21/2022 at approximately 2:24 p.m., staff were alerted to an incident where R1 was found choking in the dining room. Staff performed the Heimlich maneuver and simultaneously, a call to the local fire department and emergency services was placed. At 2:29 p.m. food obstructing R1’s airways appeared to be dislodged. Thereafter, R1 began breathing and the color returned to R1’s face. R1 was then seated in a dining room chair and suddenly became combative. The local fire department arrived on the scene at approximately 2:32 p.m. As the fire department approached the dining room, R1 became unresponsive. The local fire department immediately began CPR and per their protocol, fire department performed CPR for the next forty (40) minutes. At 3:11 p.m., R1 was pronounced deceased. Cause of death per the death certificate was asphyxia.

During the initial visit on 3/25/2022, the LPA reviewed R1's file, obtained pertinent documents and interviewed staff at 9:29 a.m. and 9:52 a.m. On 3/28/2022, additional staff interviews were conducted at 9:45 a.m., 9:55 a.m., and 10:04 a.m. A police report was requested and obtained 3/30/2022.

Based on the sheriff’s report, they did not obtain additional information which would suggest that the facility could have prevented the incident from occurring. Per the records review, R1 did not require special dietary accommodations, did not required a pureed and/or chopped diet, and was independent of facility services. Upon observation of R1 choking, the staff acted promptly and efficiently, and contacted emergency services immediately. Records review and interviews did not indicate that additional oversight was required for R1. Therefore, based on this review, no further follow up is required at this time. No deficiencies cited at this time.

Exit interview conducted. A copy of the report was issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
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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