Facility Evaluation Report

While Licensing Program Analyst (LPA) Christine Wong conducted an annual required inspection in the facility and the assistant administrator Aiona Fortaleza reported the death of Client#1 (C1) on 08/13/2021 and death report was faxed to Licensing on 08/16/21. According to the assistant manager, C1's sister called the facility and reported C1's mother found C1 on the floor at the mother's house and C1 was not responding and 911 was called and pronounced dead at 8am on 08/13/21.

During today's visit, LPA was provided with the following documents of C1:

• Identification and Emergency Information

• Needs and Services Plan dated 1/21/2019

During today's visit, LPA also interviewed assistant manager and one staff (S1) and one client (C2)

LPA advised Administrator to send a copy of the death certificate to Licensing when it becomes available.

No deficiencies were cited per California Code of Regulations, Title 22, Division 6 during this visit.

Exit interview conducted, a copy of the report was given to the assistant administrator.