Facility Evaluation Report

Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to conduct a case management visit to address an incident involving the death of Client One (C1).

The Department received an Unusual Incident Report (UIR) from the facility on 09/16/2021 regarding the emergency incident proceeding the client's death on 09/15/2021. A subsequent death report was received on 09/17/2021. The UIR details the client, on 09/15/2021, was found unconscious by Staff One (S1) in their bedroom. The report details the client, prior to death, was administered additional medication to address a health condition, for which their Primary Care Physician (PCP) provided the orders. Based on records review and interviews, the client's condition returned to normal at approximately 3:30 PM. The client requested to be transferred to their bedroom, where they were later check on at 5:39 PM. Interviews reported Staff Two (S2) contacted emergency medical personnel, who arrived approximately five minutes later. C1 was pronounced dead by paramedics at 6:10 PM.

No information was received by the LPA to indicate any lack of care and/or supervision at this time. No citations have been issued at this time.

This report was reviewed with Castillo and a copy provided.