Facility Evaluation Report

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Case Management Visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Rob Arrington, DSP. Analicia Tavarez, House Manager arrived during the visit.

During the investigation on the questionable death of Client 1 (C1). Interviews revealed that C1 choked on food at the facility on 08/07/2025 and passed away at the hospital on 08/12/2025, due to cardiac issues. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] According to C1’s physician’s report from 11/26/2024, C1 had bilateral blindness, developmental-delay, and needed staff help with feeding/eating. However, C1’s physician had not prescribed them a special diet or modified texture of food or drink. Interviews revealed C1 did not have a documented history/risk of choking on food. C1s Individual Program Plan and Annual Behavior Assessment corroborated these points. On 08/07/2025, interviews revealed that the Direct Support Professional (DSP) was the only staff member on duty during the incident. DSP has current First Aid Training. Interviews and surveillance footage revealed during breakfast on 08/07/2025, C1 was seated at the facility’s dining room table with DSP, and C1 was not left alone/unattended. Interviews revealed when C1 began to choke on food, DSP immediately observed this and took life-saving measures. Interviews revealed that DSP is seen contacting emergency services who later arrive at the facility, and took over life-saving measures.