Facility Evaluation Report

Licensing Program Analyst (LPA) Alma Gonzalez conducted a case management visit to follow-up on the death of Client 1 (C1). LPA met with Facility Coordinator Roxanne Arcibal and explained the reason for the visit. LPA interviewed Facility Coordinator Roxanne Arcibal and he stated that C1 had a surgery on 4/6/22 for Lipoma and was recuperating without any complications. According to the death report dated 4/23/22, C1 passed away on 4/23/22 at the facility. When staff attempted to wake C1 up client was unresponsive. Cause of death is unknown at the moment. C1;s health began declining since September 2021.

During today's visit, LPA reviewed documents that were submitted to Community Care Licensing Division (CCLD) via email and reviewed C1's file. LPA reviewed the following documents:

· San Gabriel/ Pomona Regional Center Placement Information

· Physician's Report/ PRN Authorization Letter/ Lab Results

· Medication Sheet dated for March 2022 -April 2022

Administrator and Facility Coordinator were asked to provide a copy of C1's death certificate when it becomes available.

Exit interview conducted and copy of Report was provided to Facility Coordinator Roxanne Arcibal.