Incident investigation·April 14, 2021

Licensing Program Analysts (LPAs) Bruce Jacobs and Michael Bilger arrived at the facility to follow up of on an incident report that was submitted by the facility to Licensing. The incident report was on the death of client (C-1) who choking on food at the home. LPAs met with Facility Administrator Sonia Gapasin as well as the care staff involved in the incident. LPA's discussed the incident, LPAs conducted additional interviews with facility staff, management and reviewed client file. Copies of file documents obtained. The LPAs requested any internal investigative reports conducted by the facility. At this time, this case management information will be reviewed with the Licensing office . LPAs will require additional time before completing the review of this incident. Exit interview conducted with the Administrator. Copy of this report provided.