Facility Evaluation Report

Licensing Program Analyst (LPA) Erik Zaragoza conducted a subsequent case management visit in response to an initial case management dated 3/18/2025 following the death of Client #1 (C1), who was found deceased in their room at the facility. During the initial visit, LPA obtained C1's FACE Sheet, most recent Physician's Report, most recent appraisal, and the Medication Administration Records (MARs) for the past three (3) months for C1. Since the initial visit, facility staff submitted the death certificate of C1 to LPA from the County of Los Angeles Medical Examiner. Today, LPA will be delivering the findings of the investigation.

On 3/12/2025, staff found C1 unresponsive in their bedroom, and subsequently called paramedics who pronounced her deceased. The death certificate of C1 explains that the manner of C1's death was natural, with the primary cause being Cardiomyopathy, and secondary causes including obesity and diabetes. The death has been determined to be not suspicious.

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 with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED .

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