Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to follow up on a self-incident/death report and met with Licensee, Josephine Credo. The purpose of this case management inspection is to follow up on a self incident/death report submitted to Community Care Licensing (CCL) on 12/04/25.

According to incident report sent in by the facility, on 12/3/25, resident R1 was found around 6:45am while staff was conducting their morning round with their right leg dangling, so staff assisted R1 to reposition their leg and remind them not to attempt to get up unassisted, R1 acknowledged and went back to sleep, then staff returned around 7:15am, but R1 was unresponsive, had shallow breathing, so staff called 911 immediately, the operator instructed them to initiate cardiopulmonary resuscitation until paramedics arrived, but R1 passed away at 8:07am. Police officers called the coroner and responsible parties were notified by the facility.

During today's visit, LPA learned through file review of R1's physician report that they had a history of chronic heart failure. LPA have requested R1's death certificate to be submitted for review and it was agreed that they will submit it once receive it. The Department will be reviewing documents once received to investigate the unexpected death of resident due to R1 was not receiving hospice services and death was unexpected.

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