Facility Evaluation Report

On 11/02/21 Licensing Program Analyst, LPA Ernand Dabuet conducted a Case Management visit to follow up on death reported for Client #1 (C1). LPA was greeted by the administrator Ana Kunz and explained the purpose of the visit was to gather information surrounding the death of (C1).

On duty desk received a copy of the death report from the facility and reported the death of (C1) on 10/26/21. The death report stated that approximately at 10:15 pm on Friday, 10/22/21 a family member called to inform management that (C1) had passed at Harbor UCLA Medical Center due to multiple injuries from an accident. According to management, (C1) was last seen on Thursday, 10/14/21 at 8:30 am leaving the facility. Carson Sheriff was dispatched and a missing person report #021-09959-1617-400 was taken on 10/15/21.

· Physician Report for Community Care Facilities,

LPA conducted an interview with staff #1 (S1) and witness #1(W1). Resident #2 (R2) was not at the facility for an interview.

An exit interview was conducted with Ana Kunz and a hard copy was provided via email for signature.