Facility Evaluation Report

Licensing Program Analyst (LPA) Ashley Calderon conducted a unannounced Case Management Visit in reference to the Death of Client #1 (C1). LPA met wirh LVN Bryawna Farmer and shortly after met with Administrator Mary Gonzales.

During the visit LPA Calderon toured physical plant with Mirafy Lopez.

LPA collected staff and resident roster, C1 Facesheet, Individual Family Service Plan, Food Menu, Staff #2 CPR certificate and Police Report Number: #CER23015-0114. On 1/30/23 C1 documents were reviewed by LPA Calderon. The following was reviewed:

Medication Log (MARS) dated for December 2022 and January 2023

Any relevant SIRs LIC 624 : 5/22/22, hospital admission for Hypotension and weakness.

Medical Assessment/Physician Report dated 9/23/22

Appraisal Needs and Services Plan dated 8/25/22

Emergency and Identification Form LIC 601 dated 8/25/21

Recent medicals records : 10/15/21 Colposcopy EMR Report, 3/16/22 Doctor Visit , 4/6/22 Gastroenterology Test Report , Memorial Care GI Procedure Summary Records / Patient Notes dated 3/3/1/22 and Gastroenterology Follow up Visit Report dated 8/25/22 (states allergic to Barbiturates- a class of depressant drug)