Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management and met with Administrator Lora Navarro. The purpose of this case management inspection is to follow up on a self reported incident report submitted to Community Care Licensing (CCL).

Per incident report, On 7/19/23 at approximate at 8:35am, upon client (C1) waking up, it was noticed by staff that C1 was having a seizure; then staff immediately contacted 911 to have C1 transported to the Emergency Room and responsible parties were notified. Doctors were able to stabilize C1, who was admitted to the hospital for further evaluation, but C1 became unstable again and passed away while in the hospital the same day at 6:21pm.

During today's visit LPA reviewed C1's records including Physician's Report dated 01/14/21 who had a diagnosis of moderate intellectual disability. C1 had been living in the facility since 1997, they were not conserved, ambulatory and verbal. LPA also reviewed C1's care plan dated 10/17/22 that indicated that C1 had been seen by their Physician in a regular basis and did not have any history of seizures.

The Department conducted an investigation into the unexpected death of client. The investigation found the facility followed all regulation and training requirements. However, C1 was not receiving hospice services and death was unexpected so Administrator agreed to submit death certificate to CCL as soon as they receive it.

No deficiencies found during today's inspection. Exit interview conducted with Administrator and a copy of this report was given.