Facility Evaluation Report

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management – Incident visit to the above facility. The LPA met with Assistant Program Director Patrice Aaron and explained the reason for the visit. Entrance interview conducted.

The reason for today's inspection is to follow up on a self-reported death report received on 03/19/2025. The report pertains to the death of Client #1 (C1). It was reported that on 03/18/25, C1 went on an outing, during the outing C1 refused to eat or drink anything. Staff 1 (S1) noticed C1's stomach was distended and brought C1 back to the DP. When they arrived at the DP at approximately 1:30 p.m. S1 told the administration and other staff that C1 needed to go to the hospital and at 1:32 p.m. 911 was called. Paramedics arrived at approximately 1:39 p.m. Paramedics took over and proceeded to do CPR. C1 passed away at the Day Proram and paramedics called the time of death.

During today's visit, the LPA conducted physical plant tour to ensure there are no immediate health and safety concerns and facility is in compliance with Title 22 Regulations, interviewed the Assistant Program Director, one (1) staff, the Licensee and obtained copies of pertinent documents and a video.

Staff informed the LPA that there was a video recording of when C1 arrived at the DP after the outing. LPA reviewed the video and obtained a copy of the video.

This incident was referred to Community Care Licensing Investigations Branch (IB) for review. Further investigation is required prior to issuing findings. An investigator or the LPA will return at a later date.

Exit interview conducted. A copy of the report was issued to the Assistant Program Director.