Incident investigation·August 27, 2025

On this day, August 27, 2025, at 1:00 p.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management in response to the Death Report (LIC624A) for resident (R1) received by Community Care Licensing Regional Office on August 25, 2025. LPA met with Executive Director (ED) Connie Kuhlmann, and informed the reason for visit. LIC624A indicated that on August 21, 2025, at approximately 1:00 pm, R1 was watching movie in the front room when R1 appeared to be in a panic attack, screaming and tried to move R1's wheelchair. The staff wheeled R1 to the medication room to be assessed. R1 became unconscious and 9-11 was immediately called. CPR was performed and R1 was pronounced dead at 4:00 pm. Police officers arrived and notified staff that the Coroners Office released the body. LPA reviewed R1's file and obtained copies of including but not limited to the following: LIC601 Identification and Emergency Information; LIC602A Physician's Report, LIC625 Appraisal/Needs and Services Plan. LPA conducted interviews. No deficiency cited during today's visit. Exit interview conducted and copy of this report provided.