565850351-6-20-2024-29-AS-ECOZ-D6ERML-20240620130854

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850351
Report Date: 06/20/2024
Date Signed: 06/20/2024 01:09:56 PM

Document Has Been Signed on 06/20/2024 01:09 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:	JM'S RESIDENTIAL CARE HOME		FACILITY NUMBER:	565850351
ADMINISTRATOR:	OHIDE, JOSEPH		FACILITY TYPE:	740
ADDRESS:	2221 KEPLER DR		TELEPHONE:	(805) 202-9208
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY:	6	CENSUS: 1	DATE:	06/20/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Crisostomo Libutan-Caregiver		TIME COMPLETED:	01:15 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 the questionable death investigation initiated on 03/07/2024 case management visit. During today’s visit, LPA Cortez met with staff Crisostomo Libutan. Administrator Rodolfo Ohide 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 Crisostomo Libutan to sign and receive the report. On 03/07/2024, from 10:30am to 1:30pm, Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management – Incident visit to the above facility. LPA Cortez met with the Elizabeth G. Mangune, co-administrator, and explained the reason for the visit. The reason for the visit was to follow up on a self-reported death report received on 03/04/2024. The report pertained to the death of Resident #1 (R1). Per the information received, the circumstances surrounding the death of R1 on 03/01/2024 were questionable and needed to be investigated. It was reported R1 was sent to the hospital on 02/27/2024 and passed away on 03/01/2024 due to septic shock. During the visit, the LPA conducted an interview with co-administrator Mangune, conducted a brief tour of the facility and obtained copies of pertinent documents. The LPA determined further investigation was required and the co-administrator was advised the incident was referred to Community Care Licensing (CCL) Investigations Branch (IB) for review. The case was assigned to Investigator Edward Hector. According to R1’s resident appraisal, R1 required total physical care for all activities of daily living (ADLs). R1 was diagnosed with autism, cognitive impairment, and used limited expressive communication. R1 also suffered from an enlarged prostate and was on a pureed diet. Additional facility file documents indicated R1 was non-ambulatory and bedridden, with health status listed as poor. R1 had a history of urinary tract infections (UTIs), sepsis, required the use of a catheter, and due to a failure to thrive a PEG (Percutaneous Endoscopic Gastronomy) tube was placed on 10/03/2023. Report will continue on LIC809-C (2ND PAGE).

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

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: JM'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 565850351
	VISIT DATE: 06/20/2024

NARRATIVE

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The records reviewed indicated R1 was being seen by Los Robles Health Care at Home (LRHH) home health agency three (3) times per week for palliative care, which included monitoring and care for catheter, PEG tube, and wound care.

R1's medical history included, but is not limited to, ESBL UTI (Escherichia coli, or E. coli, produce an enzyme called extended spectrum beta-lactamase; Urinary Tract Infection), CVA (cerebral vascular accident) with right side hemiparesis (one-sided muscle weakness), developmental delay disorder, nonverbal, seizure disorder, TBI (traumatic brain injury), Chronic Foley, and PEG (Percutaneous Endoscopic Gastronomy) tube.

According to the medical records, R1 was admitted to Community Memorial Hospital (CMH) on 01/03/2024 due to having a fever, that began the day prior. (R1 had been recently seen at the emergency department for a UTI and was already receiving antibiotics for the UTI). R1 was admitted with sepsis, felt to be secondary to recurrent urinary tract infection.

On 02/27/2024, R1 was admitted to St. John's Regional Medical Center (SJRMC). R1 was brought to the emergency department for the chief complaint of having an altered mental status due to R1 being altered from their baseline. Upon arrival to the hospital, R1 was found to be in septic shock. R1 was reportedly checked on by the residential facility staff at 1:00am and R1 was noted to have low blood pressure and seemed to be shaking a little bit. As a result, staff called 911, and advised that R1 was recently released from CMH after receiving treatment for urinary sepsis. R1’s final diagnosis included, but was not limited to, septic shock and lactic acidosis. The other conditions of R1’s final diagnosis included the majority of R1’s pre-existing health problems from their medical history. The medical records confirmed R1 had a DNR (Do Not Resuscitate) on file. R1 expired on 03/01/2024.

Report will continue on LIC809-C (3RD PAGE).

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

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: JM'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 565850351
	VISIT DATE: 06/20/2024

NARRATIVE

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Based on the information obtained from the medical records and interviews, R1 had a history of septic shock prior to the recent/last hospitalization. The LRHH home health records listed R1 had a home-based palliative care prognosis of less than one year to live. Recent medical records listed that staff observed that R1 appeared to be altered from their baseline and called 911. Upon admission to the emergency room, R1 was observed to be in septic shock. However, R1 had a history of septic shock, among many other various detrimental health conditions. The LRHH home health nurse supervisor confirmed R1’s decline in health, and subsequent death, was due to R1’s poor health. There is no evidence to support the allegation that the staff's actions, or lack thereof, contributed to R1’s death. The Department concluded that there were no deficiencies related to R1’s death at this time.

Exit interview conducted, copy of report given.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

LIC809 (FAS) - (06/04)

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