Facility Evaluation Report

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver investigation findings. LPA was granted entry into the facility and met with the Executive Director, to whom she disclosed the purpose of the visit.

Community Care Licensing (CCL) has completed the investigation into the allegation that neglect and lack of care and supervision by facility staff resulted in the death of Resident 1 (R1), identified on the LIC 811 Confidential Names List.

The investigation consisted of a review of facility records, review of the Medical Examiner’s report, review of photographic evidence, interviews with staff and outside sources, and review of physician orders and dietary records.

Department records review revealed physician documentation that R1 had multiple significant medical conditions, including dementia and oropharyngeal dysphagia. Physician’s Reports dated January 26, 2024, and May 8, 2025, documented that R1 required a soft and bite-sized diet and a minced and moist diet with thin liquids. Both physicians specifically ordered that R1’s food be modified to reduce the risk of choking. These diet orders were on file and available to staff at the time of the incident.