Facility Evaluation Report

Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Case Management Visit to follow up on a Death Report faxed to the Department on 09/02/2025. LPA met with the Administrator, Marycel Campos and LPA explained the purpose for the visit. The administrator, Marycel Campos assisted LPA with the visit.

It was reported to Community Care Licensing (CCL) received on 09/02/2025 from Fair Oaks Manor that on 09/01/2025 at 12:00pm, Client #1 (C1) was out on a day trip alone since C1 didn’t have Day Program that day. C1 was found on the ground on Fair Oaks Ave. and Penn St. by a bystander who called 9-1-1. Paramedics came to do CPR. Two police officers came to Fair Oaks Manor and talked with the Administrator and Staff #1 (S1) about the client. C1 passed away on 09/01/2025 at 2:35pm. Cause of death unknown.

During today's visit, LPA interviewed the Administrator. LPA obtained copies of C1's Individualized Program Plan (IPP), Appraisal Needs and Services Plan, Physician's Report, Medication Administration Record (MAR) from June 2025 to August 2025, and recent Medical Records.

LPA also toured C1's bedroom. No concerns, obstructions, or anything out of the ordinary was witnessed during the visit. LPA will also request facility to obtain and provide Licensing with C1's Death Certificate upon receipt if available. LPA with the Administrator and Staff #2 (S2) also went to the location of the death occurred at Fair Oaks Ave. and Penn St.

It is determined that the Case Management visit will require further investigation. No deficiencies observed during today's visit. Exit interview was held and a copy of the report was provided to the Administrator, Marycel Campos.