Incident investigation·January 25, 2022

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Case Management Visit. LPA met with Executive Director Amy Banaga, and discussed the purpose of the visit. Today's visit is in response to the self-reported death of Resident 1 (R1 - see LIC811 Confidential Names List). R1 passed away at a hospice house, date of death: 12/31/21. LPA conducted a wellness check at the facility, and no health or safety issues were identified. All staff present have a current criminal record clearance. Residents observed appeared appropriate for the facility. Additional information was obtained on this date regarding R1's death. No deficiencies were cited or observed on this date. The Licensee was provided a copy of their appeal rights (LIC9058 01/16), and his signature on this form, acknowledges receipt of these rights. An exit interview was conducted and a copy of this report was provided to Amy Banaga. An email receipt confirms the acknowledgement of these documents.