Facility Evaluation Report

Licensing Program Analysts (LPAs) Tena Herrera and Elena Mallett conducted an unannounced Case Management Visit to follow up on a Death Report that was emailed to the Department on 10/8/25. LPAs met with Mona Castro and explained the reason for the visit.

The Department received a Death Report dated 10/8/25 indicating the following: On 8/7/25 R1 was found on the street by a bystander and was complaining of abdominal pain, 911 was called and R1 was admitted to the hospital at 8:37am and was observed at the hospital for further evaluation and treatment. R1 was coded blue at 8:37pm and expired at 9:26pm. The cause of death was not specified and Medical Records were forwarded to Administrator on 10/8/25.

On 8/5/25 the Department received a Special Incident Report (SIR) that indicated the following: R1 was having a regular day on 8/2/25, had a televisit with psychiatrist at 9am and was observed near dining room before 11:30am but was noticed by staff to have missed lunch. At 11:57 S1 went to search for R1 and later at 1pm Administrator conducted a search with no luck in locating R1. Family, hospitals and local police were all notified.

Per LPA Herrera’s review of SIR’s and communication with the case carrying LPA Mallett no further SIR’s with updates have been received to the department.

On 10/10/25 LPA Mallett spoke with Administrator Mona Castro and it was confirmed that there had been a phone call received on 8/26/25 by the pharmacy stating that insurance declined medication payment due to R1 being deceased. Administrator also confirmed that on 9/15/25 a contact that handles Assisted Living Waivers contacted the facility and asked that a death report be filed. Administrator explained that there was a conversation with R1’s emergency contact where they stated that R1’s SSI funds for the month of September had not been accessed which further suggested R1 passed away. (Continued on LIC809-C)