Facility Evaluation Report

Licensing Program Analyst (LPA) Tena Herrera conducted a subsequent case management visit in response to an initial case management dated 4/3/25 following the death of Client #1 (C1), who passed away 3/17/25.

On 3/19/25 Department received a Death Report dated 3/19/2025 indicating the following: On 3/19/25 Staff #1 called paramedics for Client #1 (C1) due to weakness and difficulty breathing, 3/17/25 C1 was admitted due to decline in condition and around 6:30pm facility was contacted by C1’s family about their passing. There were no previous serious health issues/concerns.

On 4/3/25 LPA conducted the initial visit. LPA interviewed Administrator/Licensee via phone call, interviewed 1 staff in person at the facility and requested for the facility to provide the following documents: C1's FACE Sheet, Appraisal Needs & Services Plan/IPP, Physician's Report, and Medication Administration Record (MAR) for January-March 2025. Today, LPA will be delivering the findings of the investigation.

On 4/3/25 LPA received the requested documents and on 4/14/25 LPA received a copy of C1 Death Certificate. which revealed that C1's cause of death was due to Cardiopulmonary Arrest, Cardiac Arrhythmia, and Hypertension.

Based on statements and interviews conducted with staff, residents, 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.