Facility Evaluation Report

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit and met with Administrator (ADM) Jasmine Latu.

On 7/8/2025, the Department received a death report regarding a resident R1.

On 7/9/2025, LPA interviewed ADM. ADM stated resident R1 moved in the facility memory care unit room #206 on 5/16/2025. ADM stated R1 is not on hospice care. ADM stated R1 lives in a single room and without 1:1 private caregiver. ADM stated on 7/3/2025 early morning around 3:24AM, NOC shift caregiver S1 and Memory care Director (S2) were in command station area in memory care unit. ADM stated S1 and S2 heard a big bang. S1 and S2 searched for the source of the big noise, and found R1 was on the floor near the kitchenette in R1's room. ADM stated S1 and S2 called 911 immediately, and R1 was sent to hospital. ADM stated S1 and S2 notified R1's family.

ADM stated on 7/6/2025, the facility received a notice from R1's family that R1 died around 7:45AM on 7/6/2025, Sunday, in hospital. FM stated R1's cause of death is internal brain breeding. ADM stated R1 has the disease specified in the physician report dated 4/30/2025.

ADM stated on 7/5/2025, R1's family (FM) told him/her the hospital doctor told FM that R1 needs surgery for the internal brain bleeding, but R1 was too weak to go through the surgery. The hospital doctor stated R1 cannot survive more than 24 hours if R1 does not receive the surgery for internal brain bleeding.

LPA requested R1's physician report, appraisal needs and service, unusual incident report, and internal incident report. Continue on LIC809-C. Page 1 of 2.