565801271-10-17-2024-29-AS-ECOZ-DA5SGE-20241017135150

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801271
Report Date: 10/17/2024
Date Signed: 10/17/2024 01:52:51 PM

Document Has Been Signed on 10/17/2024 01:52 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	VOCATIONAL SKILLS SERVICES, INC.-ADP/OXNARD		FACILITY NUMBER:	565801271
ADMINISTRATOR/ DIRECTOR:	LAILANI G. MACASIAS		FACILITY TYPE:	775
ADDRESS:	549 WEST HUENEME ROAD		TELEPHONE:	(805) 986-8300
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY: 36		CENSUS: 20	DATE:	10/17/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:20 PM
MET WITH:	Happy Nguen-Assistant Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent case management visit to deliver findings for questionable death investigation initiated on 05/21/2024 case management visit. LPA met with assistant administrator, Happy Nguen and explained the reason for the visit. Administrator Lailani Macasias was contacted via phone and the reason for the visit was explained. Administrator was unable to be at the facility during today’s visit and authorized Happy Nguen to sign and receive the report. On 05/20/2024, the Woodland Hills Adult and Senior Care Regional Office (RO) received an incident report regarding a neglect/lack of care and supervision allegation. Client #1 (C1) sustained a brain bleed while in care of the facility and subsequently expired at the hospital. The case was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Sonia Sandoval. On 05/21/2024, from 12:50pm to 3:45pm, Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management – Incident visit to the above facility. LPA Cortez met with staff and explained the reason for the visit. Administrator Lailani Macasias arrived shortly thereafter. The reason for the visit was to follow up on a self-reported incident report received on 05/16/2024. The report pertained to an incident involving Client#1 (C1). It was reported that on 05/15/2024, C1 approached staff saying they were having a headache, and after a few minutes C1 started throwing up. It was further reported that C1 became unresponsive and was sent to the hospital. C1 passed away on 05/16/2024 at the hospital due to a brain bleed. Per the information received, the circumstances surrounding the death of C1 on 05/16/2024 may be questionable and needed to be investigated. During the visit, the LPA conducted an interview with the administrator, conducted a brief tour of the facility and obtained copies of pertinent documents. The incident was referred to Community Care Licensing Division (CCLD) Investigations Branch (IB) for review. The LPA determined further investigation was required prior to issuing findings. Report will continue on LIC809-C (2nd page).

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VOCATIONAL SKILLS SERVICES, INC.-ADP/OXNARD	FACILITY NUMBER: 565801271
	VISIT DATE: 10/17/2024

NARRATIVE

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On 07/15/2024, at approximately 11:25am, Investigator Sandoval conducted interviews with Tri-Counties Regional Center (TCRC) Service Coordinator (SC); on 07/16/2024, from approximately 9:45am to 11:35am, with the day program staff, day program Client #2 (C2), day program administrator, C1’s home facility administrator and home facility staff. In addition, the investigator reviewed St. John’s Regional Medical Center medical records, Ventura County Fire Department (VCFD) 911 audio call, Oxnard Fire Department Records, Gold Coast Ambulance Services records, copy of death certificate from the Ventura County Clerk-Recorder and Registrar’s office and facility file documents related to C1 and the investigation.

A review of C1’s Physician Report, signed and dated 02/27/2024, revealed C1’s primary diagnosis was mild intellectual disability and secondary diagnosis was mixed hyperlipidemia. It noted C1 was able to care for activities of daily living (ADLs) but unable to administer medication or leave the facility unassisted.

According to the St. John’s Regional Medical Center medical records, on 05/15/2024, at approximately 3:10pm, C1 arrived at the hospital via ambulance due to altered mentation. C1 was last reportedly seen well at approximately 1:30pm when C1 complained of a headache and went to lie down. Subsequently, C1 became unresponsive after vomiting. Paramedics were called and C1 was brought to the emergency department as a code stroke patient. Upon arrival to the hospital, C1 was intubated, and a CT scan revealed a nontraumatic large subdural hematoma (33mm) with a mass effect of 22 mm and an old right caudate nucleus lacunar infarct (stroke). C1 underwent an emergent craniectomy for evacuation of subdural hematoma. However, there was a decline in neuro exam and continual bleeding on post operative CT head despite reversal of coagulopathy and was noted as progressing towards uncal herniation. The physician communicated the status with C1’s resident representative and caregivers who opted for C1 to transition to comfort care.

The death certificate listed the date and time of death as 05/16/2024 at 7:32pm at St. John’s Regional Medical Center. The immediate cause of death was listed as acute respiratory failure and atrial fibrillation was listed as conditions leading to the cause. Other significant conditions contributing to death but not resulting in underlying cause was noted as subdural hematoma non-traumatic.

Report will continue on LIC809-C (3rd page.)

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VOCATIONAL SKILLS SERVICES, INC.-ADP/OXNARD	FACILITY NUMBER: 565801271
	VISIT DATE: 10/17/2024

NARRATIVE

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During the course of the investigation records were reviewed and interviews were conducted. The review of the EMS and 911 Call records revealed the call was made on 05/15/2024 at 2:46pm and the caller stated C1 initially complained of a headache and went to lay down (symptoms began at approximately 1:30pm. Subsequently, C1 began to vomit and no longer responded to verbal prompts but was conscious and breathing normally. The review of the medical records revealed C1 was diagnosed with a non-traumatic large subdural hematoma and subsequently expired at the hospital. The interviews with staff revealed there was no change in condition observed on C1 prior to the incident or during C1’s scheduled community outing. In addition, staff reported once C1 began to complain of a headache, the administrator proceeded to assess C1, and C1 was monitored by staff. The interview of the day program administrator revealed the facility practice when a client was not feeling well was to assess the client, inform the family or home administrator and monitor the client for a change in condition. The administrator stated they contacted C1’s home administrator who arrived approximately within 15-20 minutes and was prompted to call 911 because C1 no longer responded to verbal prompts to open their eyes. The interview of C2 revealed they did not witness a change in C1’s behavior during the 05/15/2024 community outing and had never witnessed staff mistreat or neglect clients. The interview of C1’s home administrator corroborated the sequence of events pertaining to the incident provided by the day program staff and revealed they had no concerns with the level of care provided at the day program. Therefore, the allegation “facility failed to seek medical attention in a timely manner when Client #1 (C1) complained of a headache and subsequently died at the hospital with a brain bleed” is deemed Unsubstantiated at this time.

Exit interview conducted, copy of report given.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024

LIC809 (FAS) - (06/04)

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