Facility Evaluation Report

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management visit regarding an incident report. LPA met with Staff Nelson Raguibin and explained the purpose of the visit.

On July 15, 2025, the Department received an incident report regarding resident R1. The incident report stated, On July 11, 2025 at 7:30am R1 woke up and went to the bathroom and locked the door like he/she normally does. At 7:50am staff knocked on the bathroom door to check on him/her. R1 didn’t respond to any door knocking. Then staff opened the door and found R1 on the floor unresponsive. One of the care staff did CPR on R1 while the other staff called 911. At 8:05am the fire department showed up and carried R1 to the living room and continued doing CPR on him/her. At 8:20am R1 had passed away. Staff stated R1 was in good mood all week and everything seemed to be normal this week.

The Department reviewed resident R1’s death certificate states R1’s immediate cause of death as non traumatic seizures disorder with a time interval between the onset and death noted.

The Department has completed the investigation of the above incident. Based on a review of pertinent documents, there is no indication that the death was due to staff neglect or failure to seek timely medical care.

The department has found that the allegation of neglect / failure to seek timely medical, as UNFOUNDED , meaning that the allegations were false, could not have happened and/or are without a reasonable basis.