Incident investigation·November 29, 2021

Licensing Program Analyst (LPA) Lizzette Tellez conducted an unannounced case-management visit. LPA was met by Caregiver, Lilia Deona, and was granted entry into the facility. LPA met with Licensee/Administrator, Chona Simsuangco, and discussed the purpose of the visit. This visit was initiated due to the death of Client #1 (C1). Ms. Simsuangco was provided with Confidential Names Form, in order to identify C1. It was reported to Community Care Licensing (CCL), that C1 passed away on 10/13/21. During today's visit, LPA toured the facility, conducted interviews, and reviewed C1's records. A copy of C1's death certificate was requested to be provided by Ms. Simsuangco once received. No immediate health and/or safety concerns were observed during the visit. No deficiencies were cited during today's visit. An exit interview was conducted with Ms. Simsuangco, and a copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) were provided to them via email. An electronic receipt of confirmation was requested to be sent by the Administrator upon receipt of the documents.