Facility Evaluation Report

Licensing Program Analyst (LPA), Mayra Cota, initiated a case management visit to follow-up on the death of Client #1 (C1). LPA was met by Eric Espartero, Administrator and Rhea Lynn Castillo, House Manager and the reason for the visit was explained. During visit, all clients were attending day program.

The facility sent the department a Special Incident Report (SIR) regarding the passing of C1 on 10/11/25 at around 6:45 p.m. According to SIR, C1was heard gasping for breath while in bed. Staff on duty provided C1 with assistance to help clear the cough; however, C1became unresponsive. Staff proceeded to call 911 and paramedics arrived at 6:43 p.m., along with law enforcement. Paramedics performed CPR on C1 but stopped when staff provided Physician Orders for Life-Sustaining Treatment (POLST) documentation, indicating C1 is on a “do not resuscitate” status. Paramedics stopped CPR and informed facility staff C1 was asystole. Administrator and House Manager arrived to the facility shortly after. Police called conservator/family member regarding C1’s passing and family member arrived to the facility thereafter. At around 9:20 p.m. that evening, a mortuary service picked up C1’s remains and taken to a cemetery. Family member indicated to staff, they will be in contact with them about C1’s services.

During today’s visit, LPA toured the home, obtained copies of staff and client rosters, and obtained C1’s administrator timeline for 10/11/25, psychiatric evaluation report and Psychiatric Medication Consultation report. Prior to today’s visit, facility staff emailed LPA the following documents on 10/16/25: C1’s Physician Report, Individualized Program Plan (IPP), face sheet, MAR for August, September and October, 2025, Physician Progress notes, Police Report case number and SIR from 10/11/25. Also, during today’s visit, LPA obtained the contact information for C1’s conservator/family member, Staff 3 – Staff 4 (S3-S4), and Regional Center Service Coordinator.