Facility Evaluation Report

Licensing Program Analyst (LPA) Natalie Gayoso conducted an in-office case management meeting and met with Administrator Arcelia Laygo.

The purpose of today’s visit was to discuss the investigative findings pertaining to the death of Client #1, (C1).

It was alleged that Client #1 (C1) died due to possible neglect and lack of supervision. On 9/28/20 the department received notification that Client #1 (C1) was struck by a car after being discharged from the hospital. The department’s investigation into C1’s death included file review, interviews with staff/residents/witnesses, and collecting pertinent records.

On September 25, 2020 at 5:20pm C1 was transported to the hospital due to an injury to the right leg. C1 was transported by ambulance alone due to Covid-19 restrictions. At 6:30pm hospital personnel informed the facility that C1 was ready for discharge and facility staff was scheduled to be there in 20 minutes. At 7:10pm C1 screamed during discharge and ran out of the hospital. The RN was unable to apprehend C1 but hospital security chased C1. C1 was seen crossing the Highway. When facility staff arrived at the hospital, they were directed towards the direction were C1 went. The hospital called the police and facility staff started searching for C1. Facility staff was later informed that C1 was struck by a car and killed. Based on the investigation the allegation questionable death due to lack of care is unfounded. The department has found that the allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis.

An exit interview was conduct, and a copy of this report was provided to the Administrator