Facility Evaluation Report

Licensing Program Analysts (LPAs) Steve Chang and Mita Partoza, conducted an unannounced case management visit to deliver the finding of the incident that occurred on 09/04/2023

On 9/5/2023, the Department received an incident report regarding the death of a resident herein referred to as R1.

On 9/14/2023, the department conducted a case management visit and met with Licensee/Administrator (LIC/ADM) Bernellet Taa and gathered the following documents that includes but not limited to Appraisal Needs and Services Plan (LIC 625) dated 08/18/2023. Physician’s Report (PR) dated 8/14/2023 and Personnel Report (3/11/2023).

On 9/4/2023, at around 1749 hours (5:49 P.M.) R1 left the facility without the staff’s knowledge. Staff were not aware that R1 did not come back to the facility until the morning of 9/5/23 at around 0900 (9:00 A.M.) S1 notified ADM that R1 was missing. ADM instructed staff to look for the resident inside and outside of the facility. S1 called the family member herein referred to as F1. F1 informed S1 that R1 is deceased and did not want to provide additional information.

On 9/6/2023, the facility’s video surveillance recording was viewed and showed R1 walking out of the facility’s front driveway at 1749 hours (5:49 P.M.) of 9/4/2023 unassisted.