Facility Evaluation Report

Licensing Program Analysts (LPAs) Marcella Tarin and Manuel Monter arrived unannounced to conduct a Case Management Visit to follow up on the death of Client C1 on 3/19/2025. LPAs met with Administrator Jocelyn Perez and stated the purpose of the visit.

On 3/19/2025 the Department received an Incident Report. The incident report stated that on "March 19,2025 C1 woke up around 12AM midnight, asking staff for warm water and complained of stomach pain. After drinking water, C1 went back to his/her room to sleep. At 3AM C1 woke up with loose bowels, staff helped C1 shower and change. Around 8AM Valley Health Connection was contacted for C1, and facility was instructed to take C1 to Emergency Room (ER). Prior to leaving for the ER, C1 wanted to take a shower. During shower, staff noticed C1 was about to fall and ADM called 911. 911 operator instructed ADM to keep C1 awake. Paramedics around 9AM and took over, performing CPR on C1. Local law enforcement arrived after and called the the time of death." Incident Report states Licensing and San Andreas Regional Center (SARC) and C1's family were informed.

During visit, LPAs obtained the following copies to include but not limited to admission agreement, physician's report and service plan, interdisciplinary meeting documents, Individual Program Plan (IPP), Behavioral Support plan, Centrally Stored Medication and Destruction Record (CSMDR), Medication Administration Record (MAR) and After Visit summaries.

ADM stated to LPAs the facility will provide a copy of R1's Death Certificate once it becomes available.

LPAs determined this case management needs further investigation.

No deficiencies cited during today's visit. This report was reviewed with ADM Jocelyn Perez and a copy of the report was provided.