Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a case management visit on 5/13/24 at 1:15p. LPA met with Cynthia Cruz-Maduro and stated the purpose of the visit.

Community Care Licensing (CCL) received an Incident Report (LIC624) indicating that resident #1 passed away at the facility.

CCL received the (LIC624A) Death Report dated 5/10/24, Individual Program Plan (IPP) dated 3/7/2024, (LIC602) Physician Report dated 1/10/24, (LIC627C) Consent for Emergency Medical Treatment dated 12/14/23.

LPA conducted an interview with Administrator who indicated that R1 was medication compliant, ate well with no complications and/or complaints, except for eye redness with no pain for which a doctors appointment had been scheduled for the day of the incident.

LPA met the relative of resident #1 (R1) who stated that a copy of the death certificate will be given to the facility who then in turn can send a copy to CCL.

At this time, there is no mention of cause of death. The relative is not sure yet.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies are being cited during this visit.

Exit Interview held, and a copy was provided.