Facility Evaluation Report

Licensing Program Analyst (LPA) Erik Zaragoza conducted a subsequent unannounced case management visit in regards to the passing of Client #1 (C1). LPA met with Joan Cole, Direct Support Staff for the facility, and explained the purpose of the visit. Administrator Jourdan Sanvictores arrived shortly thereafter.

The investigation consisted of the following: During the initial visit conducted on 4/4/2025, LPA interviewed Staff #1 (S1), and obtained C1's Physician's Report, FACE Sheet, Individual Program Plan (IPP), and their Medication Administration Records (MARs) for the past three (3) months. Since the initial visit, LPA obtained a copy C1's death certificate.

The investigation revealed the following: C1 was found in their room on 4/1/2025 by staff at around 2:00 AM and was non-responsive. Paramedics were called after it was discovered C1 did not have a pulse, paramedics arrived and pronounced C1 deceased at 3:15 AM. Staff explained that there were no signs that C1 had any issues with their health in the days leading up to their passing. The death certificate revealed the C1 passed away due to complications from Down's Syndrome.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur that the death of C1 was suspicious, and therefore the concern is UNSUBSTANTIATED .

Exit interview held, and a copy of this report was provided.