Facility Evaluation Report

On this day at around 12:15 p.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management in response to the Death Report for resident (R1) submitted by Joseph Crisol, administrator. LPA met with house manager, Crizaldo Robles, and explained the purpose of the visit. LPA called and spoke over the phone with the administrator. Administrator stated he can not come to the facility, and authorized the house manager to sign and received this report.

Death report indicated that R1 passed away on 8/12/24 at approximately 8:10 am. Staff did not notice anything out of the ordinary with R1 prior to R1's death. Staff also did not notice any changes in condition day prior to R1's death. When staff was calling residents for breakfast, R1 was observed not responding. 9-1-1 was called immediately. The first responder and deputies declared R1 deceased. The administrator called and informed R1's family member (FM).

LPA obtained copies and reviewed the following: LIC601 Identification and Emergency Contact Information; Appraisal/Needs and Services Plan; doctor's order of medications; Medication Administration Record; Physician's Visit Forms; LIC622 Centrally Stored Medication and Destruction Record. LPA interviewed staff and FM, and checked the medications.

2. Quantity of 1 medication remaining not consistent with what should be based on the start date recorded on LIC622. The medication with 90 quantity filled on 5/22/24 has remaining 72 tablets when should be 48 based on date the medication started 7/01/24.

3. LIC622 not completely filled-up; some do not have record of quantity received and strength.