Incident investigation·December 9, 2025

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with DSP staff, Eduardo Chico and Olive Jackson. Dennis Abadilla, Administrator Designee, arrived shortly and LPA stated the reason for the inspection. LPA observed (2) clients resting in the front common area, a third client resting in their room. A fourth client was attending day program. LPA and Administrator Designee discussed (2) recent incident reports submitted to the Department for client (C1) who was hospitalized on both occasions. (C1) has a renal mass on both kidneys. Client (C1) was hospitalized on November 12, 2025 after receiving results from blood work done two days prior and admitted for testing and fluid hydration. (C1) was discharged on November 16, 2025, and the facility was given instructions to continue to monitor for signs/symptoms related to the renal mass. Discussions of surgery and options most viable to (C1) are ongoing. On November 25, 2025, (C1) was taken to a follow up appointment with urology following hospitalization and for foley management. Due to having a low blood pressure reading, the Urologist recommended (C1) be evaluated further in the Emergency Room. The incident report states that upon arrival to the ER, Diagnostic procedures including an x-ray, urinalysis and blood draw were completed. Medication to increase blood pressure was administered via IV and (C1) was admitted to the Intensive Care Unit (ICU) for (4) days. It was determined (C1) had sepsis due to a possible infection related to the catheter. Medications were changed, including a Beta Blocker, Propranolol, which was paused at the last hospital stay. The facility will continue to monitor blood pressure 2x/day and communicate with the primary care physician (PCP). LPA reviewed blood pressure logs which document blood pressure has increased. (C1) will continue to be seen weekly by both a home health nurse and a facility nurse. The facility is awaiting a call from the PCP to schedule a follow up. There are no deficiencies issued in this report. Exit interview. Copy of report provided