Facility Evaluation Report

Licensing Program Analyst Manuel Monter conducted an unannounced case management regarding an incident report that was submitted on November 2, 2023. LPA met with (ADM) administrator Anita Dela Cruz & explained the purpose of the visit.

On November 2, 2023, the department received a death report stating resident R1 was unresponsive when he/she arrived from the day program. R1 was taken to the emergency room. R1 subsequently passed away at the hospital. R1's death is unknown at this time. ADM will provide death certificate once it becomes available. San Andreas regional center and R1's responsible party is aware.

LPA interviewed S1, S2 and ADM regrading the incident that occurred on 11/01/2023.

LPA requested the following documents/ video footage from the administrator:

Ring-Video footage of the incident, R1's physicians report, R1's appraisal needs and services plan, R1's pre-appraisal, R1's IPP, facility progress notes regarding R1. Centrally stored Medication, MAR, BM Log, communication log with the day program, R1's emergency form. PRN Log. & seizure log.

No deficiencies cited during todays visit. Report was reviewed with ADM Anita Dela Cruz and a copy was provided.