Facility Evaluation Report

Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Case Management Visit to follow up on a Death Report faxed to the Department on 12/26/24. LPA was allowed entry by S2 and explained the purpose of the visit. Administrator, Ann Hyde arrived shortly after and LPA explained the purpose for the visit. Administrator, Ann Hyde assisted LPA with the visit.

It was reported to Community Care Licensing (CCL) received on 12/26/2024 from Ambitions - 183rd Street that on 12/21/2024 at 3:50am, C1 was having difficulty breathing and balancing, home staff assisted C1. Home staff contacted 9-1-1. Paramedics transported C1 to the hospital. C1 went into cardiac arrest and was put on life support. C1 passed away on 12/24/24 at 1:50am.

During today's visit LPA interviewed the Administrator and S1. LPA obtained copies of C1's Face Sheet, Individualized Program Plan (IPP), Physician's Report, Medication Administration Record (MAR) from September 2024 to January 2025 and the Special Incident Report (SIR) prior to the incident.

LPA also toured C1's bedroom. No concerns, obstructions, or anything out of the ordinary was witnessed during the visit. LPA will also request facility to obtain and provide Licensing with C1's Death Certificate upon receipt if available.

It is determined that the Case Management visit will require further investigation. No deficiencies observed during today's visit. Exit interview held and a copy of the report was provided to the Administrator, Ann Hyde.