Facility Evaluation Report

Licensing Program Analyst (LPA) S Vaid conducted a case management visit for the death of Client #1 (C-1). LPA met with Jolanda Cartridge-Intermin Administrator for the facility and explained the purpose of the visit.

The facility submitted a death report for C-1 who passed away on 4/01/2025 at Torrance Memorial hospital.

According to the death report and interview with the DSP Vivian Yates, C1 had autism and seizure disorders. No history of drug/alcohol abuse. Service coordinator at Harbor Regional was aware of the clients' condition. C1 was non-verbal, low functioning. C1 was able to communicate by hand gestures. And was spoon fed by the staff.

On 2/28/25 C1 had a seizure or heart attack, lost consciousness and 911 was called and was transported to the hospital. C1 went to the hospital and was released to the facility on 3/05/25. On 3/06/25 C1 had a heart attack and was taken to the hospital by paramedics. Three (3) clogged arteries were noticed. On 3/27/25 C1 was admitted to Torrance Memorial Hospital awaiting surgery on 04/01/25. On 4/01/25 C1 went into cardiac arrest 2x and was unable to be revived.

Facility notified Harbor Regional and Licensing 04/02/25.

LPA requested and obtained copies of the following documents: C1's Face sheet, Physician's Report, MAR log for January, Feburary and March 2025, and IPP Regional Center annual report.

LPA Vaid also requested for a copy of the death certificate when it becomes available.

An exit interview was conducted, and a copy of this report was provided to the Administrator Jolanda Cartridge.