Incident investigation·September 29, 2023

At 8:50 a.m. on 09/29/2023, Licensing Program Analyst (LPA) Nicholas Reed and Licensing Program Manager (LPM) Naira Margaryan conducted an unannounced case management visit. LPA and LPM met with the co-Administrator and disclosed the reason for the visit. Today’s case management visit was conducted after the facility submitted an incident report in which Resident #1 (R1) and Resident #2 (R2) required medical assistance due to severe injuries on the morning of 09/20/2023. R1 experienced rib pain, and R2 was found bleeding and unresponsive. The facility later submitted R2's death report. LPA and LPM interviewed staff and residents between 9:00 a.m. and 11:00 a.m., reviewed records at approximately 10:15 a.m. and 11:30 a.m., and toured the facility at approximately 10:40 a.m. Multiple deficiencies were observed during the physical plant tour and record reviews including but not limited to deficiencies in personal accommodations and services, admission agreements, physical plant, and basic services. Deficiencies will be addressed during an Informal Conference held at the Woodland Hills-South Adult and Senior Care Regional Office. Exit interview conducted. Copy of report provided.