Facility Evaluation Report

Licensing Program Analyst (LPA) Tena Herrera conducted a subsequent case management visit in response to an initial case management dated 11/8/24 following the death of Client #1 (C1), who passed away 10/29/24. LPA met with Marilou Kulberg - RN and explained the purpose for todays visit.

On 10/31/24 the Department received a Death Report via fax that stated the following: on 10/28/24, 12:30pm, C1 was brought to PMD clinic for pre-op clearance for cystourethroscopy. Doctor saw C1 and prescribed antibiotic, Levaquin 500mg via G-Tube x5 days for pneumonia and sent C1 home. 10/28/24 at 8pm C1 looked very weak, breathing fast, heart rate 132-142, oxygen on 3L/M, oxygen saturation 88-90%, BP – 115/59. Temp – 96.9F. Doctor was notified and gave order to transfer to ER/Coast Plaza Hospital. 10/29/24, 9:30am hospital reported C1’s death with time of 8:22am.

On 11/8/24 LPA conducted initial visit and Interviewed Administrator Ayub Walaya who stated that whenever C1 had UTI or Pneumonia their heart rate increased, C1 had gone to the doctor in the morning of 10/28/24 to get clearance for a surgery, the doctor prescribed medication for pneumonia and later that afternoon, and C1 returned to facility. C1 began to look lethargic and weak, staff called the doctor and were instructed to take C1 to the ER. C1 passed the following morning 10/29/24 in the hospital. C1 has had a history of UTI and Pneumonia SIR's have been submitted for C1’s multiple doctor visits and hospitalization's. LPA obtained copies from C1’s file: FACE Sheet, Death Report, Appraisal Needs & Services Plan, Physician's Report, and Medication Administration Record (MAR) for August - October 2024. LPA toured C1's bedroom. No concerns, obstructions, or anything out of the ordinary was witnessed during the visit. LPA requested facility to provide Licensing with C1's Death Certificate upon receipt.

On 1/6/26 LPA received a copy of C1’s Death Certificate with the cause of death listed as: Cardiopulmonary Arrest, Cardiac Arrhythmia, and Pneumonia.

Based on statements and interviews conducted with staff and review of C1's files and death report the cause of death does not appear to be suspicious or due to any neglect, therefore the findings are UNSUBSTANTIATED . Exit interview held, and a copy of this report was provided.