Facility Evaluation Report

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Case Management - Incident visit to follow up on a visit made on 11/19/2025 regarding an Incident Report the Department received on 11/18/2025. LPA Rai met with Administrator, Sam Apostol , and stated the purpose of the visit.

On 11/18/2025, the Department received an LIC 624 Incident Report stating on 11/17/2025 resident R1 was found unconscious and staff called 911 in response and R1 was transported to the hospital. Administrator Sam Apostol was informed R1 passed away at the hospital the same day.

On 11/19/2025, the Department conducted a visit at the facility to follow up on the Incident Report. LPA Rai received information from Administrator, Sam Apostol and two staff members. Three out of three staff stated on 11/17/2025 staff heard R1 fall in the bathroom and observed R1 on the floor unconscious. The facility staff called 911 and paramedics transported R1 to the hospital. ADM stated R1 passed away at the hospital due to cardiac arrest.

During this investigation, Death Certificate was not able to be released to the Department due to Health Insurance Portability and Accountability Act (HIPPA). LPA Rai contacted a representative of the Office of the Medical Examiner (OME) of County of Santa Clara who stated "[R1]'s death was ruled as natural".