Facility Evaluation Report

On April 3, 2026, at 2:30 PM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced Case Management Visit to follow-up on a death report received from the facility. LPA Kim met with Administrator (ADMIN) Liezl Tuason.

During today’s visit, LPA conducted a health and safety check, and there were no imminent health/safety concerns observed. Facility is maintained at a comfortable temperature for the clients care. LPA obtained Staff Roster, Client Roster, and C1’s records which includes the Physician’s Report, Facesheet, Appraisal and Needs/Service Plan, Medication Administration Record, Integrated Progress Notes, Incident Reports, Hospitalization records, and other pertinent documents. LPA interviewed two staff and one witness.

Based on record review, the Incident report received by the Orange County Regional Office on April 3, 2026, R1 was sent to the hospital on April 2,2026, around 6:10 AM, Client #1 (C1) experienced a sudden change in condition. C1 became cyanotic, with a heart rate of 56 and oxygen saturation in the low 80s while on the ventilator. Staff immediately initiated rescue breathing via tracheostomy using an Ambu bag and called 911. Paramedics arrived and departed the facility with C1 at 6:22 AM. When C1 arrived to the emergency, C1 went into cardiac arrest. Prior to C1’s death, C1 had been undergoing treatment for a urinary tract infection since March 27, 2026. C1 experienced intermittent fever and tachycardia, which were managed by their primary care physician. C1’s condition appeared more stable throughout April 1, 2026.