Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Chitgian arrived to the facility to gather documentation related to an adult death of client #1 (R1). LPA met with staff Ariel Pascualsia (AP) and spoke with Administrator Cielta Ravelo, (CR) over the phone at the facility. CR explained that the day prior to the incident, on 3/1/2023 there was nothing unusual with R1. The client had been showing signs of having tremor and unsteady gait. Doctor appointments were made for 3/15/23 with neurology. The client was also described as walking like “a hunchman, bowing down”. The day of the incident, on 3/2/2023, morning medication was given and he was called to the dining room for breakfast when R1 had a face-forward fall. R1 broke his tooth and had a nosebleed. Staff assisted with First Aid and called 911. Time was noted at 8:55AM. Paramedics arrived by 9:15AM when R1 was taken to Kaiser Ontario Hospital. Later that day, R1 was transferred to Arrowhead Regional Center and remained at the hospital until his demise on 3/10/2023.

LPA requested the clients file/folder. Review of documents, LPA observed the Date of Birth for the client is noted as :12/26/1958, and not 1985 as submitted in the Death Report- LIC 624A to Community Care Licesning office. True age of client is 65 years.

LPA asked AP to please correct Date of Birth listed on the Death report.

LPA obtained the following documentation during today's visit: Medication Administration Record (MAR) Special incident report, staff CPR certificate, P&I ledger, Client rights form, admission's agreement, client's physician's report, IRC IPP, weight log, prescribed medications, medical report, resident property and centrally stored medication record, death report.