Facility Evaluation Report

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management - incident visit to deliver the investigation finding on that the facility Neglect/Lack of supervision resulted in resident R1's death and met with Clinic Manger Bory Kham (BK).

On 05/16/2023, the Department received a incident/death report from the facility that a resident (R1) was found unresponsive on the floor in the bedroom .

On 05/17/2023, an initial Case Management - Incident investigation visit was conducted. LPA toured the facility with ADM including resident R1's bedroom. R1's physician report, Appraisal Needs and Service Plan, emergency contact, Progress Notes, police report case number, and Admission Agreement were obtained.

On 09/22/2023, the Department interviewed facility staff (S1) at the facility and obtained documents.

On 09/26/2023, the Department reviewed staff records and resident R1's records at the facility, and interviewed Administrator (ADM), 4 staff (S2 - S5) and 1 resident (R2).

On 01/06/2023, the Department interviewed staff (S6) at the facility.

Based on the interviews and records reviews, R1 was admitted to the facility on 12/07/2023. Based on R1's progress note dated 12/08/2022 and 5/02/2023, R1 has a history of drug use and with psychotic disorders. Based on interviews with staff on 09/26/2023, R1 relapsed and was tested positive for drugs during R1's stay at the facility. R1 was prescribed medications which help with the drug cravings, but R1 refused to take it.