Incident investigation·January 4, 2024

On 01/04/2024 at 10:00AM Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct a case management visit to follow-up on a incident report and death report received by Community Care Licensing on 11/10/2023. LPA met with both General Manager, Linda Fisher and Care Director, Yelba Havelhorst and explained the purpose of the visit. Staff 1 (S1) stated that on 11/04/2023 at approx. 6pm, Resident 1(R1) fell in the dining room after getting up from dinner. S2 assessed R1 and applied first aid to R1's laceration on forehead. 911 was called and R1 was transported to John Muir Hospital In Walnut Creek (John Muir). S1 stated that she went to John Muir to pick up R1 after 9pm because R1 was getting discharged. S1 stated that the Emergency Room (ER) nurse at John Muir informed that R1 was weak and would need a wheelchair. S1 stated that R1 was independent and really did not want to use a wheelchair but went ahead and used the wheelchair. S3 stated that on 11/06/2023 they were looking for R1 to go to dinner. S3 stated that when the resident returned back from the hospital R1 was weak and using a wheelchair. S3 stated that R1 was "very independent." S3 stated at around 5pm they went to R1's apartment and found R1 unresponsive faced down on the floor. S3 stated, "knew that he was gone." S3 further stated that it appeared that R1 was trying to place his clothes on. S3 stated that the police arrived and pronounced R1 deceased. S3 stated that the paramedics also were called and arrived on the scene and pronounced R1 deceased. LIC809-C LIC809-C Continued.... R1 passed away on 11/06/2023 with an unknown cause of death. During today's visit LPA obtained additional information pertaining to R1's death: 1. Resident Incident Report (Aegis Living Pleasant Hill) dated 06/03/22 2. Unusual Incident Report (LIC 624) dated 10/23/23 3. Physician's Report (LIC 602A) dated 05/26/23 4. Individualized Service Plan dated 10/04/23 LPA requested from facility a copy of R1's death certificate. LPA was informed by General Manager that family will provide R1's death certificate, once available and will provide CCL a copy. No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided.