Facility Evaluation Report

On 12/23/22 at 11:30 am Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a case management in response to the Special Incident Report (SIR) for resident (R1) submitted by the facility to the Department. LPA met with staff Terisita St. Maria, and later met with another staff, Soliman Dela Cruz. LPA called and spoke with Aidan Castrence, administrator, over the phone and informed the purpose of visit. Castrence cannot come to the facility and authorized Teresita St. Maria to sign and receive this report.

SIR indicated that R1 woke up at 7:30am daily routine, shower, drank medication, ate breakfast, and assisted back to his room at 8:45am. At 11am staff went back to check on R1 staff found R1 was not responsive. Staff performed CPR until the paramedic arrived and tried to revive R1 for 45min. Paramedic could not revive R1. R1 cause of death is Unknown.

LPA conducted interviews. Mr. Castrence indicated he's in the process of obtaining a copy of death certificate.

LPA requested Mr. Castrence to submit the following by 12/27/22:

1. requested for a copy of death certificate as soon as it becomes available

2. LIC601 Identification and Emergency Information

4. Most current Appraisal/Needs and Services Plan and Individual Program Plan

5. Copy of proof of primary care physician's last visit (any conversation regrading R1 health condition)

Copy of this report provided on this same day to Terisita St. Maria.