Incident investigation·October 27, 2021

---- This is an amended report to remove confidential information ---- At 9:30 AM on 10/27/2021, Licensing Program Analysts (LPAs) Nicholas Reed and Wendell Smith met with Designated Administrator for an unannounced case management visit. The current census is 4 residents. LPAs toured the facility at 9:45 AM inside and out. LPAs noticed a COVID-19 screening station at the front door, full of masks, gloves, gowns, a thermometer, and a visitor log. LPAs observed all rooms in clean and tidy order. All rooms had televisions, dressers, clean linens, pillows, and lamps. Bedrooms #4 and #1 were private bedrooms with exit doors leading outside. Bedrooms #2 and #3 were shared rooms. LPA asked 3 out of 4 residents how they like living at the facility, and all replied similarly, stating that it is very clean and relaxing. At 10:02 AM, LPAs interviewed Administrator. LPA asked Administrator to describe C1 and C1's medical conditions. Administrator stated C1 had dementia and used diapers. C1 was ambulatory and coherent. C1 wore glasses as prescribed, though sometimes would take them off. C1 enjoyed exercising every day with a caregiver, and C1 liked to drink coffee outside. LPA asked Administrator to recall C1's fall on 10/16/2021 Administrator stated C1 seemed fine. C1 just woke up. Administrator was in her office and Caregiver S1 changed C1. Both saw C1 sitting on the bed with two feet on the floor. One minute later, S1 saw C1 slumped over by his bedside. C1 reported falling and scraped an elbow. Administrator and caregiver observed a small amount of blood. Administrator asked how C1 fell, and C1 responded, “Oh, I just slid down”. Administrator called 9-1-1. C1 independently stood up and walked to the bathroom. When the ambulance arrived, C1 laid down in a gurney and was transported to the hospital. ---- This is an amended report to remove confidential information ---- LPA asked when C1 realized C1's hip was broken Administrator stated C1 realized after the physician told C1 at the hospital. LPA asked when C1 underwent surgery. Administrator responded it took a few days for C1's public guardian to sign for the surgery. On 10/19/2021 C1 underwent hip surgery. On 10/20/2021, a nurse from Kaiser called Administrator stating C1 was ready to return to the facility. Administrator inquired if C1 needed rehabilitation prior to returning to the facility. The nurse explained C1 would not require rehabilitation. Kaiser provided Home Health Care upon return. LPA asked about the day of C1's death. Administrator stated C1 ate breakfast in the morning and the caregiver changed C1's diaper. Around 10:00 AM, caregiver noticed C1 was not breathing. Administrator called 9-1-1, and the fire department, police, and ambulance arrived to the facility. Fire department pronounced C1 dead around 10:45 AM, and C1's body was taken to Crawford Lorenzen Mortuary at 8717 Tampa Ave, Reseda CA 91553. LPA will follow up with Administrator when cause of death is determined. Exit interview conducted and report emailed.