Facility Evaluation Report

Licensing Program Analyst (LPA) conducted an unannounced case management visit at this facility to follow up on the incident occurred on 02/23/26 wherein Resident #1 (R1) choked while at the facility and eventual death at the hospital on the same day. LPA met with Administrator Florida Malla and explained the reason for the visit.

LPA conducted a physical plant tour at 10:08 AM, requested copy of facility documents at 10:35 AM, reviewed records between 10:35 AM to 11:35 AM and interviewed the Administrator between 11:35 to 12:15 PM. LPA interview with the Administrator revealed that R1 had a habit of stealing food from Resident #2 (R2) and had a habit of shoving food to own mouth. Further, at the time of the incident R1 stole the individual pizza from R2 while smoking at the backyard. The Administrator was at the bathroom during the incident but was immediately informed by R2 that R1 passed out at the backyard. The Administrator saw R1 unconscious at the floor and saw R1's mouth filled with the pizza crumbs, the Administrator attempted to remove the food from R1's mouth and did a Heimlich maneuver but did not remove all the food in R1's mouth so Administrator called 911 and was instructed to do CPR while waiting for the paramedics to come. Paramedics arrived about ten (10) minutes later and took over, stayed for an hour and then bring R1 to the hospital where R1 eventually passed. LPA record review revealed that R1 was able to feed, bath, shower, dress and groom on R1's own.

There is no health and safety issues during this visit. Exit interview conducted. Copy of this report issued.