Facility Evaluation Report
Licensing Program Analyst (LPA) Christine Yee conducted an unannounced case management visit to deliver the findings of the investigation conducted for the death of Resident #1 and met with Hector Gomez, Assistant Administrator. The reason for today’s visit was provided.
On the morning of 3/13/23, LPA Yee received a telephone call from Marty Bacon, Administrator, advising her of the death of Resident #1 and a Death Report was faxed over later in the day. Resident #1 had been involved in a fatal automobile accident.
An initial case management visit to the facility was conducted on 3/14/23 to obtain information about the circumstances surrounding the death of Resident #1 and to determine if the facility had neglected to provide the appropriate care and supervision to the resident, resulting in the fatal accident. During the initial visit, interviews were conducted with Marty Bacon, Administrator, at 12:18pm, Hector Gomez, Assistant Administrator at 1:31pm, and Staff #1 at 1:53pm. LPA also toured the site of the automobile accident at 11:54am and reviewed Resident #1’s file at 2:10pm to determine if the resident is able to leave the facility unassisted. Per review of facility documents, Resident #1 has a primary diagnosis of Schizophrenia and is conserved. An attempt was also made to interview Resident #1’s roommate to obtain information about anything unusual that may have been observed about Resident #1 on 3/10/23 and was unsuccessful. The roommate was sleeping during the visit. LPA was also advised by staff that the roommate would not be a credible witness to Resident #1’s state of mind on the morning of the accident.
Per information received from interviews conducted with staff on the initial visit, Resident #1 was observed behaving like normal self on 3/10/23. Resident #1 had breakfast, listened to loud music, smoked, did not complain of any health issues and did not exhibit any suicidal ideations prior to leaving the facility and before being involved in the fatal accident. Per review of Resident #1’s Physician’s Report, the resident is able to
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction