Incident investigation·July 28, 2022

On 7/28/2022 at 12:55PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to death report received on 7/26/2022. LPA met with Business Office Director, Jocelyn Sanjuan. Senior Executive Director, Parveen Singh arrived a couple hours later. Death report dated 7/26/2022 stated that R1 was found unresponsive on 7/22/2022 and staff called paramedics. R1 has a DNR on file. R1 passed away at the facility on 7/22/2022. During visit, LPA reviewed R1's file and observed physician's report dated 7/15/2022 stated that R1's primary diagnosis was Cerebral Infarction affecting right dominant side, Dysphagia, and CHF. R1's secondary diagnosis was Chronic Kidney Disease and Vascular Dementia. Facility notes indicated that R1 did not eat much for a couple days prior to passing. Interview with staff indicated that R1 did not eat much prior to moving into the facility. Paramedics pronounced death on 7/22/2022. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.