Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management- Incident visit to follow up on Death Report (LIC 624A) submitted to this licensing agency on 06-09-2023. Client #1 (C1) was discovered in their bed having labored breathing and not responding to staff on 06-08-23 around 9am. Immediate cause of death is unknown at this time pending coroner investigation. Between 8:45 am and 9am Staff #1 (S1) entered C1’s room and found C1 to have labored breathing and unresponsive. Staff called 911 and performed CPR until paramedics arrived. C1 was pronounced deceased by first responders upon arrival.

During today’s visit, LPA requested and obtained a copy of C1’s file including current medical assessment (annual and monthly report), C1’s most current IPP, most recent physician’s orders, most recent Functional Capability Assessment, Admissions Agreement, Medications List, and most recent physician’s report. LPA conducted two staff interviews. LPA requested and obtained a copy of Staff #1 (S1) file and contact information. LPA requested facility obtain a copy of the death certificate and forward the certificate to this licensing agency.

At this time there are no deficiencies to cite. LPA will continue to gather additional information from staff and other agencies. LPA will return once additional information is gathered. A copy of this report was emailed due to printer problems.