Incident investigation·September 3, 2021

Licensing Program Analysts (LPA) Bruce Jacobs 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 passed away at the home. On 04/14/21, LPAs Bruce Jacobs and Michael Bilger met with Facility Administrator Sonia Gapasin as well as the care staff involved in the incident. LPA's discussed the incident and reviewed staff and resident files. 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. This case management information was reviewed by the Licensing Analyst. Interviews and file documentation document that staff was assisting the client with lunch. The client began to choke on his lunch at which time the other staff in the home was alerted to the situation and called 911 Emergency Services. Staff was directed and did perform CPR until Emergency Services arrived in approximately 3 to 5 minutes and continued with resuscitation measures. The client expired at that time. Staff files documented that staff had a current CPR/First Aid certification (expires 5/8/2022). Client's Physician's Report documented the need for assistance with meals and requirement for small bites, as described by direct care staff. No deficiencies were identified in this case management incident review. Exit interview conducted with the Administrator. Copy of this report provided.