Facility Evaluation Report

Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced Case Management - Incident visit to this facility and met with staff and the Administrator Collins Akinsola was contacted and arrived at the facility shortly after. LPA explained the reason for the visit.

On 04/23/2025, Community Care Licensing (CCL) received a death report for Client #1 (C1). It was reported that on 04/22/2025, C1 was not symptomatic during the day. C1 attended Day-Program in the morning and as routine the breakfast and lunch was served at the Day-Program. C1 was on a puree diet per the Physician's order. At approximately 5:00 PM, C1 ate his/her dinner (a pureed banana and 1 1/2 burrito) at the facility and the staff did not observe any unusual behavior or reaction. At approximately 7:00 PM, C1 took his/her prescribed medication. LPA was informed that no new/recent medication or any changes in the medication was ordered by C1's Physician. At approximately 8:00 PM, C1 went to bed. At approximately 8:37 PM, C1 started screaming and the staff entered the room to check on C1. Staff found C1 with a lot of bowel movement and vomit. Additionally, C1 was having difficulty breathing. In the meantime, the Administrator called 9-1-1 and before the Paramedics arrived C1 passed away. T he coroner's report and death certificate have not been received yet. Furthermore, during today's visit LPA toured the facility and conducted an interview with the Administrator and one (1) staff. LPA also reviewed complete facility records including medication for C1.

No deficiency is issued during today's visit and LPA determined that another visit will be conducted and will return at a later date.

Exit interview conducted. A copy of the report was signed and provided.