Facility Evaluation Report

On July 15, 2025, Licensing Program Analyst (LPA) Ernand Dabuet conducted a Case Management visit to follow up on the death reported for Client #1 (C1). Assistant Administrator Mata Fonopo and House Manager Dario Esguerra greeted LPA. LPA explained that the purpose of the visit was to gather information surrounding the death of (C1).

The regional office received a copy of the death report on July 14, 2025, from the facility that reported the death of (C1) on July 13, 2025. The death report stated that (CI) passed away at the facility in (C1's) room. According to the incident report, C1) was admitted to Olivia Isabel Manor as a client on 02/04/24. The report states that (C1) had missed 8:00 PM meds and that (C1's) roommate attempted to wake (C1) while asleep but appeared to be unresponsive. The roommate, known as (C2), alerted the medical staff, who called Emergency Medical Services. EMS conducted CPR and subsequently pronounced (C1) dead.

According to staff #1 (S1, C1), the client had a cough before death and did not want to see a medical doctor or go to the hospital. (C1) was complaining about taking medications daily, and there have been no changes in (C1's) prescribed medications. In addition, (S1) reported that (C1) had no history of any substance abuse and had no recent medical attention. The facility notified (C1's) family member by telephone of (C1's) passing.

ID and Emergency Information (dated: 03/15/23)

Physician Report for Community Care Facilities LIC 602A (dated: 03/18/25)

Preplacement Appraisal Information LIC 603 (dated: 01/30/25)

Medications (MAR) (dated 07/01/25 through 07/31/25)

Incident Report LIC 624 (dated: 07/14/25)

An exit interview was conducted with Mata Fonopo and a hard copy was provided.