Facility Evaluation Report

Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility following notification of the death of a client in care. The LPA met with Administrator, May Embalsado, and informed her of the purpose of the visit.

The Department was notified, on February 17, 2022, of the death of Client One (C1) via a Serious Incident Report (SIR). According to the report, C1 passed away on February 16, 2022 at the hospital. Additional information in the report indicates C1 was hospitalized on January 31, 2022 through February 04, 2022 with a diagnosis of sepsis without acute organ failure.

On this visit the LPA conducted Staff and client interviews, reviewed records, and took copies of pertinent documentation. According to Administrator Embalsado, the client was prescribed with several medications, including several antibiotics for COVID-19 and Urinary Tract Infection (UTI). A medication audit revealed the medications were administered appropriately. Client interview reported staff did check on C1 regularly and provided a good quality of care, generally. Interviews also reported C1 was observed at 3:00 AM on February 16, 2022, to have low oxygen. Due to the low oxygen reading, staff contacted emergency medical services (911). Staff reported C1's oxygen continued to lower when checked by medical personnel. The client was transported to a local hospital where they were reported to have passed away at 8:10 PM. No health and safety violations were observed at this time.

This report was reviewed with Embalsado and a copy was provided.