Facility Evaluation Report

Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced case management visit. LPA Williamson identified herself and was granted entry into the facility by the receptionist. LPA stated the purpose of the visit and reviewed the basic elements of the visit with Kimberly Keane, Director of Program Development and Gerardo Godinez, Senior Residential Support Manager.

On May 25, 2022, the facility self reported the death of Client 1(C1) (See LIC 811 Confidential Names List) to Community Care Licensing. The facility reported that on May 24, 2022, Caregiver Karrina Koskinen observed that C1's breathing pattern had changed to a shallow and faint breathing. Hospice staff, Senior Residential Support Manager were contacted and reported to the facility. Robert Richardson, LVN confirmed that there was no pulse nor vital signs present in C1. C1 was pronounced deceased on May 24, 2022 at 10:50 PM at the facility. C1 was admitted to hospice care on April 22, 2022.

During today's visit, LPA conducted staff interview, and requested and obtained records. No deficiencies were cited during the visit.

An exit interview was conducted with Gerardo Godinez, Senior Residential Support Manager and a copy of this report, LIC 811 and Licensee Appeal Rights (LIC9058 01/16) were provided.