Facility Evaluation Report

Licensing Program Analyst (LPA) Bonnie Tao conducted an unannounced Case Management- Incident visit in response to Client (C1’s) Incident Report that was submitted by John Bromstead, Administrator on 11/11/21. The report was for a death that occurred on 11/11/21. LPA explained the purpose of today's visit to Lorraine Bromstead, Administrator, who assisted with this visit.

During today's visit LPA toured the facility, interviewed Administrator/Staff (S1), clients (C2- C5), and reviewed C1's file. The incident report stated C1 deceased due to complications of surgery. C1 passed away at the hospital. LPA did not observe nor identify signs of neglect, abuse or other immediate health and safety threats.

LPA obtained copies of the following documents:

· C1’s Medication Administration Records (MAR)

· C1's Unusual Incident Report, dated 11/11/21

· C1's Identification/Emergency Contact Information (facesheet)

· C1's Last doctor visit dated 6/14/2021 and 10/5/2021.