Facility Evaluation Report

Licensing Program Analyst, Amber Coleman (LPA) arrived at the Zion Adult Residential Facility to make an unannounced case management visit due to a recent death of a resident while in care of the facility. LPA introduced self and stated the purpose of the visit. LPA was greeted by Unique Watkins, Administrator and invited inside of the facility. LPA was asked to sign in and have temperature taken. Administrator contacted the Licensee to notify her of LPA's visit. Licensee arrived later during LPA's visit.

This case management visit consisted of collecting pertinent documentation and conducting staff interviews in regards to the death of Resident #1 (R1).

LPA and Administrator took a seat in the living room to conduct an interview. LPA asked Administrator to explain the incident and how it happened. Administrator reported that she was not on shift the evening of 12/17/22 but reported to work on 12/18/22 at 8:00am for her shift. Administrator relieved the Licensee of her duties. Administrator was only staff on duty for the day. Licensee gave report to Administrator, which did not specify anything unusual. The evening prior (12/17/22) the resident returned from day program, had a snack, went outside with another resident to smoke. When she returned back inside she played dominoes, ate dinner, assisted another resident with making their bed, took medications and went to bed herself. The next morning, Licensee informed Administrator that she did not get a chance to assist the residents with