Facility Evaluation Report

Licensing Program Analyst (LPA) Alma Gonzalez conducted a case management visit to follow-up on the death of Client 1 (C1). LPA met with Director Kimya Oliver and explained the reason for the visit. According to the death report dated 07/08/24, C1 passed away on 07/07/24. Immediate cause of death noted on LIC 624A Death Report is noted as Hypoxia and Cardiac Arrest. Conditions contributing to death are noted as C1 was hospitalized on 06/16/24 due to low oxygen levels and was intubated twice/ pending tracheostomy.

The facility provided the following documents prior to the visit:

Unusual Incident/ Injury Report dated 07/08/24

Physician's Report for Community Care Facilities LIC 602

Copy of C1's medication record for month of June 2024

During today's visit, LPA reviewed C1's facility file and interviewed Director Kimya Oliver and copies of the following documents were provided:

Preplacement Appraisal Information LIC 603

Copy of C1's medication record for month of May 2024

Director Kimya Oliver was asked to provide a copy of the death certificate when it becomes available.

Exit interview conducted and copy of Report was provided to Director Kimya Oliver .