Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management Visit Incident- on 07/23/2026, in regard to a Death Reporting Form (LIC 624A) of a client#5 (C5) and Unusual Incident/Injury Report (LIC 624) dated 05/05/2026. LPA Ramirez was greeted by Administrator Leilani Libang and explained the purpose of the visit.

On 04/14/2026, C5 was observed to be ill and was taken to a local hospital for further evaluation and was later admitted. On 05/02/2026, C5’s family updated C5’s health directive due to a decline in C5’s health and placed C5 on hospice care. On 05/05/2026, C5 passed away at a local hospital.

LPA Ramirez requested and obtained copies of the following documents: Client#5 (C5) Face Sheet, Emergency contact information, Individual Personal Plan (IPP), Medication Administration Record (MAR) for the April 2026, and physician’s orders.

No deficiencies are being cited today. LPA Ramirez requested a copy of C5’s death certificate from Administrator Libang. At this time, C5’s is not considered suspicious. Exit interview conducted and a copy of this report was emailed.