Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management Visit on 06/22/23 at 4:00pm. The purpose of this visit was to deliver findings based on initial Case Management visit dated 01/04/23, regarding the death of Client #1 (C1). LPA Ramirez was met by Administrator Tonya Saunders and explained the purpose of the visit.

On 01/03/23, LPA Ramirez received Death Report (LIC 624A) and Special Incident Report indicating C1 was found unresponsive by Staff #1 (S1) and Staff #2 (S2). Staff called 911 around 5:40 am and EMS (Emergency Medical Services) arrived at the facility at 5:46 am. On 01/04/23, LPA Ramirez conducted a Case Management visit and interviewed S1, S2 and gathered pertinent documents related to this investigation. On 01/09/23, IB Referral was sent and accepted as an IB Investigation. On 03/21/23, IB Investigation found that in the 911 recording, S1 could be heard, twice, advising the 911 operator that they (S1 and S2) were performing CPR on C1 during the call. Interviews conducted by LPA Ramirez and IB Investigator revealed that S1 and S2 denied performing FIRST AID/CPR on C1 although S1 indicated to the 911 operator that they (S1 and S2) were performing FIRST AID/CPR. Investigation findings SUBSTANTIATED- NEGLECT-FAILURE TO PERFORM CPR/FIRST AID ON A CLIENT.

Based on investigation findings, deficiencies are being cited. On 06/22/23, this licensing agency issued an ORDER TO LICENSEE/FACILITY OF IMMEDIATE EXCLUSION FROM FACILITY and ORDER FOR IMMEDIATE EXCLUSION FROM FACILITY and LPA Ramirez physically served Administrator Saunders and S2.

A copy of this report, 809-D and Appeals Rights were provided.