Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management visit and met with Administrative Assistant Charito Santos. The purpose of this case management visit is to follow up on a self reported death report submitted to Community Care Licensing (CCL) dated 4/5/26 involving resident (R1) along with incident report. LPA is following up on this death report due to R1 was not receiving hospice services when they unexpectedly passed away on 4/5/26.

Per incident report, on 3/26/26 around 11:45am staff observed R1 was not at their baseline and could hardly eat, then staff called 911 immediately, paramedics transported R1 to the hospital for further evaluation. Responsible parties were notified. Per death report, “on 4/5/2026 at approximate 2:30pm, R1 passed away while in the hospital due to them not been able to breath on their own.

During today's visit, LPA conducted interviews with staff, requested documentation regarding R1's health condition prior to their passing. LPA's review of R1's physician's report (LIC602) dated 12/17/24 indicates that R1's diagnosis was sepsis and urinary tract infection (UTI) and was unable to perform activities of daily living. LPA obtained R1's Needs and Services Plan (LIC625) supports physician's diagnosis. Based on interviews with staff there is no indication that they noticed anything unusual prior to R1's unexpected decease. On 4/9/26, LPA requested the facility to obtain R1's Death Certificate and provide to CCL once received. The Department will review information once is obtained to determine if further actions are needed.

No deficiencies cited during today's visit. Exit interview conducted with Administrative Assistant and a copy of this report was given.