Facility Evaluation Report

Licensing Program Analyst(LPA), Christine Yee, conducted an unannounced case management visit to investigate the circumstances surrounding the death of Resident #1. LPA Yee met with Hector Gomez, Assistant Administrator. Also participating in today's visit was Stephen Manalo, Staff. The reason for today's visit was explained.

On today's visit, LPA Yee obtained copies of Resident #1's file, interviewed the Assistant Administrator at 11:31am, Staff #1 11:15 am, Staff #2 at 1:18pm and Staff #3 at 1:40pm. Resident #1's bedroom was toured at 1:50pm.

Per information obtained, Resident #1 had spent the prior week with family and returned to the facility on the evening of 12/9/24 around 6:00 or 6:30pm and went to their room. Resident #1 had already had dinner with family. Resident #1 had returned with a new cell phone and went to the central desk to obtain a pass word to hook their phone to wi-fi. The staff working at the time did not know the password so Resident #1 went back to their room. Approximately an hour later, Resident #1 went back to central station and asked for another staff who was not scheduled to work that day. Resident #1, who is a smoker, was observed going in and out to smoke and finally went to bed around 10:30pm. Resident #1 was observed laying on their side during room check conducted at 3:30am and was again observed in bed when room check was conducted at 6am. At around 8:40 or 8:50am the housekeeper went to clean Resident #1's room. The housekeeper knocked on the door and when there was no response, the housekeeper entered the room. Resident #1 was observed laying horizontally across the bed, face down, with arms spread out and legs hanging off the bed. Staff tried to wake the resident and there was no response. Staff went to call the Assistant Administrator and they both returned to the room. Resident did not have a pulse and did not respond. 911 was contacted. The paramedics checked Resident #1's pulse and used a stethoscope on Resident #1's back and pronounced them deceased at 9:31am. The paramedics informed staff not to touch anything in the room and