Incident investigation·July 1, 2022

Licensing Program Analyst (LPA) Galarza conducted an unannounced Case Management- Incident visit to obtain information on the death of a resident (R1) that occurred on June 26, 2022. The purpose of the visit was explained to Senior Executive Assistant Marilou Mendoza. Executive Director Liyon O'Quinn was explained the purpose of the visit telephonically. The incident and death report states that on Sunday, June 26, 2022 at 11:40 AM, resident (R1) was found on the ground outside building Leitzel Hall (LH). The resident sustained major injuries. 911 emergency and LAPD responded to the incident. Resident (R1) was pronounced dead at the scene. Preliminary findings indicate the resident fell from it's 5th floor room balcony. T he facility sent facsimile notification to Community Care Licensing Division (CCLD) on June 26, 2022. LPA toured the exterior facility grounds and resident (R1's) 5th floor room. The balcony railing was observed to be approximately 36 inches (3 ft) high. The following documents were obtained: Resident (R1's) file documents. Please submit the most recent Physician's Report. Personnel Report/Staff schedule. Resident Roster LAPD incident report # Facility staff was instructed to obtain resident (R1's) Death Certificate and LA County Coroner's report t and submit to CCLD. Exit interview was held with Senior Assistant Marilou Mendoza. A copy of the report was issued.