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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801727
Report Date: 03/07/2024
Date Signed: 03/07/2024 03:04:15 PM

Document Has Been Signed on 03/07/2024 03:04 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:SAINT ROQUE FAMILY HOME CAREFACILITY NUMBER:
565801727
ADMINISTRATOR:BARBARA BROWNINGFACILITY TYPE:
735
ADDRESS:1610 KIPLING COURTTELEPHONE:
(805) 874-1762
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 6DATE:
03/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Barbara Browning TIME COMPLETED:
03:05 PM
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Allegation: Staff did not seek medical attention in a timely manner, which resulted in client’s death.

Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent case management visit to deliver findings for the above allegation. LPA met with staff Carmen Constantino and explained the reason for the visit. Administrator Barbara Browning arrived at the facility at 2:54 p.m.

On 09/28/2023 at 10:18pm, the facility administrator called Community Care Licensing (CCL) and left a message reporting that Client #1 (C1) had passed away. According to the administrator, the staff went to check on the clients before they went to bed and noticed C1 was not in bed. The staff checked outside and found C1 outside. C1 was breathing initially but then stopped and the staff administered CPR until the paramedics arrived. Paramedics worked on C1 for 45 minutes before C1 was pronounced dead. According to the administrator, C1 did not have any recent change in conditions or decline in health. The administrator stated earlier this year C1 started losing weight and was seen by the doctor who referred C1 to a hematology doctor. According to the administrator, C1 had blood work on 09/14/2023 and it came back normal.

On 10/03/2023, between 9:40am and 11:25am, Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Incident visit. At 9:40am, LPA Peraldi met with the staff and explained the reason for the visit. At 9:56am, the administrator arrived at the facility. The reason for the visit was to follow up on a self-reported death report received on 09/28/2023. The report pertained to the death of C1. At 9:56am, an interview was conducted with the administrator and Staff #1 (S1). At 11:06am, the LPA conducted a brief tour of the facility. During the time of the visit, the LPA obtained copies of pertinent documents. The administrator was informed a referral was made to the Community Care Licensing Division (CCLD) Investigation Branch (IB) and an additional report would follow if warranted.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
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: SAINT ROQUE FAMILY HOME CARE
FACILITY NUMBER: 565801727
VISIT DATE: 03/07/2024
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A review of the Ventura County Autopsy Report revealed that C1 had a history of schizophrenia, tobacco use, and prior methamphetamine abuse. C1 was not known to be suicidal. The Autopsy revealed C1 with a hemorrhagic gastric ulcer and with apparent hemorrhage within the gastrointestinal tract. There was no evidence of fatal trauma. Toxicology performed on postmortem blood was negative for common drugs of abuse. The cause of death was listed as Gastrointestinal Hemorrhage due to Gastric Ulcer. Contributing factor was listed as Atherosclerotic Cardiovascular disease. The manner of death was listed as natural.

Based on the review of the medical records, investigative findings, and other miscellaneous documents, C1 had multiple physical and mental conditions, and the licensee might not have been aware of C1’s condition of gastric ulcer, therefore the staff could not seek medical attention in a timely manner. The Department concluded that there were no deficiencies related to C1’s death at this time.

Exit interview, copy of report given.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC809 (FAS) - (06/04)
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