Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management- Incident visit to follow up on Death Report (LIC 624A) submitted to this licensing agency on 01-03-2023. Client #1 (C1) was discovered unresponsive and pronounced dead at approximately 5:45am on 01-03-23. Immediate cause of death according to the death report is unknown at this time pending coroner investigation. Report states C1 diagnosed with seizures, Angelman Syndrome, Cerebral Palsy, Tremors, Autistic, Intellectual Disability, and Dysphagia. At approximately 5:35 am staff entered C1’s room and found C1 to be unresponsive. Staff called 911 and waited for paramedics. Paramedics arrived and did not attempt life saving measures according to staff. They announced she was too far gone.

During today’s visit, LPA requested and obtained a copy of C1’s file including current medical assessment (annual and monthly report), C1’s most current IPP, most recent physician’s orders, most recent Functional Capability Assessment, Admissions Agreement, Medications List, and most recent physician’s report. LPA conducted two staff interviews. LPA requested a copy of Staff #1 (S1) and Staff #2 (S2) file and contact information. Administrator will email this information by 01-06-23. LPA requested facility obtain a copy of the death certificate and forward the certificate to this licensing agency.

At this time there are no deficiencies to cite. LPA will continue to gather additional information from staff and other agencies. LPA will return once additional information is gathered.

*Amended on 01/05/23- signed electronically by Administrator Saunders on 01/05/23