Facility Evaluation Report

Licensing Program Analysts (LPAs) Elena Mallett conducted an unannounced initial Case Management Visit to follow up on a Death Report that was emailed to the Department on 01/22/2026 LPAs met with Staff 2 (S2) who contacted Administrator Jon de la Cruz and explained the reason for the visit. Administrator de la Cruz and Licensing Program Analyst (LPA) Bonnie Tao joined the visit shortly after.

On 01/21/2026 Licensing received a Death Report for Client 1(C1). C1 passed away on 01/21/2026 at 12:23 PM after vomiting and becoming unresponsive. Emergency Responders were called but unable to save C1. Cause of death and Death Certificate are pending.

During the visit, LPA Mallett interviewed administrator, staff#1 (S1) and staff#2 (S2). C1’s file was reviewed.

Facility Visitor Log Nov 2025-Jan 2026 and Home Health Nurse Visitor Log Dec 2025- Jan2026

Staff notes related to C1 (12/27/25-01/21/26)

Home Health Care Plan and Physician's Orders.

Harbor Regional Center IPP dated 12/04/25,

C1’s LIC 601 Personal Identification and Emergency Information and ID

C1’s Medication Administration Records (MAR) - December 2025 and January 2026,

C1’s Vista Specialty Hospital Nurses Notes ( Skilled Nursing Facility),