Facility Evaluation Report

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced case management visit in response to a reported death incident of Client #1 (C1), who passed away on 11/14/2025. LPA met with Imelda Jonson, House Manager and explained the purpose of the visit. Carol Liess, Administrator was also called and explained the purpose of the visit. Shortly after, Katrin Silvestro, Supportive Services Coordinator arrived and assisted LPA.

The incident report stated that Staff #1 (S1) heard a loud thud in C1's room at about 8:00 am on 11/14/2025 and discovered C1 face down on the bedroom floor , bent forward . S1 called out C1's name and asked as to whether C1 was okay , but there was no response. S1 immediately called 911, where S1 was told to administer CPR. After approximately 5 minutes, EMTs arrived and took over performing CPR on C1. The paramedics transported C1 to the ambulance via gurney. Unfortunately, after 15 minutes, the EMTs informed S1 that C1 had passed away and took C1's body back to the room. The Pasadena Police were also present and remained until the LA County Coroner took C1's body around 6:00 pm.

During today's visit, LPA toured the physical plant including C1’s bedroom and found no issues, obtained staff and client rosters and C1's Exer Urgent Care visit (11/12/2025). LPA interviewed Staff #1 (S1) - Staff #2 (S2) in person and Staff #3 (S3) on the phone. LPA also requested the Administrator to provide the EMT/Paramedics report, police report and C1's death certificate to CCL when they become available.

Prior to the visit, LPA Pena obtained C1's files such as; Death report, Unusual incident/injury report (SIR dated 11/14/2025), Physician's report, Needs and Services plan, Face Sheet, Medication Administration records (Sep-Nov 2025), Pasadena Police report number PA 25-88380.

No citations issued at this time. An exit interview was held and a copy of this report was provided to Katrin Silvestro, Supportive Services Coordinator.