Facility Evaluation Report

Licensing Program Analyst (LPA) Kathleen Banrasavong made an unannounced visit to conduct a case management visit for Resident 1 (R1)’s death. LPA toured the facility and did not observe any immediate health and safety concerns. LPA conducted a health and safety check and met with Administrator, Melissa Sumibcay and explained the purpose of today’s visit. At the time of the LPA’s visit, there are four (4) residents who live at the facility but two (2) residents present at the facility during the LPA’s visit. There was one (1) staff member present at the time of the visit.

During the LPA’s visit, LPA reviewed, requested, and obtained copies of pertinent documentation, conducted staff interviews regarding R1’s death on 01/28/2025. LPA reviewed and requested copies of the Needs and Services Plan, Medical Assessment, Medication Logs, Medication list, Admission agreement. LPA interviewed to obtained further information regarding the death of R1 and the events that led up to R1’s death. The Administrator stated that she went into the hospital on 01/27/2025 for Pneumonia . However, the cause of death is unknown at this time, to the facility. LPA advised the Administrator, Melissa Sumibcay to send a copy of the death certificate to the department, as soon as it becomes available.

No deficiencies were cited during this visit, as there were no health and safety concerns observed during today's visit.

An exit interview was conducted and a copy of this report, the LIC 811 were provided to the Administrator, Melissa Sumibcay.