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 12/29/2025. LPA was allowed entry by Jessica Corona, Direct Support Professional and explained the purpose of the visit. Administrator, Phillip Jordan arrived shortly after and LPA explained the purpose for the visit.

It was reported to Community Care Licensing (CCL) received on 12/29/2025 that on 12/27/2025 at 10:09am, Client #1 (C1) began vomiting dark liquid while heavily breathing in C1’s room. Home staff contacted 9-1-1 at 10:09am. Staff began CPR when C1 went unconscious. Paramedics arrived at 10:14am and took over CPR and other procedures. C1 passed away at the Raymond House at 10:36am on 12/27/2025.

During today's visit LPA interviewed the Administrator. LPA obtained copies of C1's Face Sheet, Individualized Program Plan (IPP), Appraisal/Needs and Services Plan, Physician's Report, Quarterly Behavior Assessment, Medication Administration Record (MAR) from October 2025 to December 2025, the Special Incident Reports (SIR) prior to the incident and other pertinent documents.

LPA also toured C1's bedroom. No concerns, obstructions, or anything out of the ordinary was witnessed during the visit. LPA requested the facility to obtain and provide Licensing with C1's Death Certificate upon receipt if available.

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