Facility Evaluation Report

On 07/27/2026 at 12:20 PM, Licensing Program Analyst (LPA) P. Manalo conducted an unannounced Case Management visit to follow up on the incident report dated 07/18/2026. LPA met with Administrator (ADM), Desiree Fredeluces, and explained the purpose of the visit.

Incident report dated 07/18/2026 stated that on 07/17/2026 at around 6:30 PM, C1 complained of left leg discomfort while staff were conducting their rounds. Around 7:30 PM, C1 was still not feeling better and told staff that maybe C1's legs hurt because C1 overdosed. Incident report stated, C1 was upset and took all of C1's medication dosages from C1's backpack. At around 7:50 PM, C1 was found unresponsive and C1's doctor was notified and 911 was initiated. On 07/20/2026, C1 returned back to the facility from the hospital.

During the visit, LPA interviewed ADM and ADM stated that on 07/17/2026, staff were attending a meeting and did not retrieve C1's medication from C1's backpack when C1 returned. LPA reviewed the following documents included but not limited to the DDS report, the facility incident report, physician report, Health Condition Care Plan, Individual Health & Nursing Care Plan dated 07/22/2026, Behavioral Support Plan dated 07/25/2026, Staff Schedule, Staff Contact Information, After Visit Summary, ABC Data Collection dated 07/17/2026, and Nurses Progress Notes dated 07/17/2026.

LPA and ADM discussed documentation during time of incidents, conducting reassessment when needed, and ensuring that medications are locked and inaccessible to clients.