Facility Evaluation Report

Licensing Program Analyst (LPA) Tena Herrera conducted a subsequent case management visit in response to an initial case management dated 8/28/25 following the death of Client #1 (C1), who passed away 8/26/25. LPA met with Melanie De Ocampo - Caregiver and explained the purpose for todays visit.

On 8/26/25 the Department received a Death Report indicating that on 8/12/25 C1 was hospitalized, during hospitalization C1 was placed on Hospice Care and was discharged back to facility on 8/21/25. On 8/26/25 at 7:30pm C1 was pronounced deceased and their hospice nurse was with C1 in last moments until C1 passed.

On 8/28/25 LPA conducted the initial case management visit and interviewed 2 Caregivers and obtained copies of the following documents within C1’s file: Physician’s Report, Face Sheet, Incident Report, Hospice Documentation, and Medication Administration Records (MAR) for the past 3 months (June-August 2025). LPA requested for the facility to provide the following documents via email: C1's most current Appraisal/Needs and Services Plan, and Hospice Notification.

LPA toured C1's bedroom. No concerns, obstructions, or anything out of the ordinary was witnessed. LPA requested facility to obtain and provide Licensing with C1's Death Certificate upon receipt.

On 9/18/25 LPA received copies of C1’s Appraisal/Needs and Services Plan, and Hospice Notification.

On 11/24/25 LPA received a copy of C1’s Death Certificate with the cause of death listed as: Respiratory Arrest and Chronic Systolic Congested Heart Failure.

Based on statements and interviews conducted with staff and review of C1's files and death report the cause of death does not appear to be suspicious or due to any neglect, therefore the findings are UNSUBSTANTIATED . Exit interview held, and a copy of this report was provided.