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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701161
Report Date: 06/17/2024
Date Signed: 06/17/2024 11:40:22 AM

Document Has Been Signed on 06/17/2024 11:40 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MARCONI VILLAFACILITY NUMBER:
342701161
ADMINISTRATOR/
DIRECTOR:		DHANOA, MANPREETFACILITY TYPE:
740
ADDRESS:2100 MARCONI AVENUETELEPHONE:
(916) 571-5270
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 6CENSUS: 5DATE:
06/17/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Manpreet DhanoaTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator Manpreet Dhanoa and explained the purpose of the visit.

LPA Moleski reviewed a death report for a resident (R1). According to the death report, R1 died by choking on 6/9/24. Staff performed the Heimlich maneuver. Three staff members were present at the time (S1-S3), and 911 was called, according to the death report. According to Dhanoa, R1 choked while eating a chopped sausage with a bun for lunch, and attempts to remove the obstruction were ineffective. First responders declared R1 deceased upon arrival, according to Dhanoa.

LPA Moleski reviewed R1's LIC 602, dated 11/19/23. R1 was diagnosed with dementia and had no special dietary restrictions, according to the LIC 602. R1 was able to feed themselves, according to the LIC 602. R1 was admitted to this facility on 12/8/23. LPA Moleski reviewed R1's file and observed no physician's orders regarding special dietary restrictions.

According to S2, there was an incident approximately three months ago wherein R1 had some difficulty with eating, and appeared briefly to be choking. 911 was called, but R1 was fine and did not need medical attention. LPA Moleski reviewed daily notes for 3/19/24 and observed a note stating that R1 "choke on a hot dog," and that 911 was called. R1's doctor was notified but did not provide any special dietary restrictions. LPA Moleski reviewed a doctor's note dated 3/21/24 indicating that R1's doctor recommended "coaching with eating."

[continued on 809-C]
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MARCONI VILLA
FACILITY NUMBER: 342701161
VISIT DATE: 06/17/2024
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LPA Moleski interviewed S1-S3. All three corroborated the narrative presented in R1's death report. According to S1, S1 was providing one-on-one care to R1 on 6/9/24 when R1 started to choke on the chopped sausage while eating outside. S2 said that S2 had chopped the sausage and served it to R1. S1 said that S1 performed the Heimlich maneuver on R1 after R1 started choking, and called for help from the other staff, who were inside. S3 said S3 arrived and tried to assist S1, and called out for S2. S2 came outside and took over performing the Heimlich maneuver. S3 had to return inside to continue assisting another resident. S1 called 911, and S1 and S2 continued performing the Heimlich maneuver and followed dispatcher instructions until first responders arrived. First responders declared R1 dead upon arrival.

LPA Moleski reviewed staff files for S1-S3. All three had current first aid and CPR training records.

No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Dhanoa.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC809 (FAS) - (06/04)
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