Incident investigation·June 6, 2025

On 06/06/2025 at 11:50 AM, Licensing Program Analyst (LPA) P.Manalo arrived unannounced to conduct a case management visit in regards to death report received on 06/02/2025. LPA met with Executive Director, Simone Hall, and explained the purpose of the visit. Death Report indicated that Resident 1 (R1) was found unresponsive during room rounds and first responders pronounced R1 deceased at around 2:53 AM. LPA obtained R1's Physician's Report, Service Plan Report, and Physician's Fax Report of Falls. R1 had sustained multiple falls within the last couple months with no apparent injuries. Executive Director stated that the facility implemented for staff to do more check-ins with R1 at night, and usually R1 would be in the activity room throughout the day. Executive Director will reach out and obtain a death certificate. Executive Director will notify LPA once obtained. LPA may return at a later time. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.