Facility Evaluation Report

Licensing Program Analyst (LPA Elena Mallett conducted an unannounced subsequent Case Management to follow up on a Death Report that was emailed to the Department on 01/22/2026. LPAs met with staff in charge, Mercedes Bedolla and explained the reason for the visit. Staff contacted Administrator Jon de la Cruz by phone and LPA spoke with Administrator and discussed the purpose of the visit.

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.

On 01/22/2026 LPAs Elena Mallett and Bonnie Tao conducted an unannounced initial Case Management visit to the facility. During that visit the Administrator Jon de la Cruz and two staff members were interviewed. Staff and client rosters were obtained in addition to the following documents for C1: Face sheet, 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, Physician Report dated 07/07/25, Harbor Regional Center IPP dated 12/04/25, LIC 601 Personal Identification and Emergency Information and ID, Medication Administration Records (MAR) - December 2025 and January 2026, Vista Specialty Hospital Nurses Notes , Menus for January and February and Home Health nurses’ contact information and Incident reports dated 11/19/25 and 01/04/26. Also obtained was S1’s CPR/First Aid card. LPA s toured the physical plant including C1's room and LPAs did not observe any health and safety risks.

During today’s visit a staff and client roster were obtained and tour of the physical plant was conducted. No immediate health and safety concerns were observed.