Incident investigation·May 6, 2025

On May 6, 2025 Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced 24 hour case management visit to gain additional information pertaining to the death of a resident (R1) that was reported to the Regional Office (RO) on May 5, 2025. LPA Lee met with Nicole Lozano, Admissions Director who granted access to the facility and the purpose of the visit was explained. Subsequently, Jenni Gordon Administrator arrived to assist with the visit. On May 5, 2025 at 7:42 am R1 was found laying on side in a fetal position observed to have a knife lodged in his abdominal cavity. 911 called, and first responder observed that resident was deceased on arrival. An investigation was conducted by Long Beach PD and based on their investigation; the stabbing appeared to be self-inflicted. LPA Lee and Jenni Gordon conducted a tour of the facility. The following documents were obtained/reviewed: Staff roster Resident roster, R1 and R2 files, Physician's Orders (dated 5/5/25) for R1 and R2, Physician's report for R1 and R2 (dated 3/25/25 and 10/29/24 ), copy of County of Los Angeles medical examiner investigator's card-case number 2025-07419), Search Warrant and Affidavit (dated 5/5/25), LBPD search warrant property report (dated 5/5/25), Individual Service Plans for R1 and R2 (dated 4/21/25, 1/30/25). Medication Administration Record (MAR) for R1 and R2. LPA observed the meeting Administrator and psychologist Dr. Salman Shully had with the residents informing them of what happened and offering any grief counseling if anyone needed it. There were no deficiencies cited during today’s visit. An exit interview was held and a copy of the report was provided to Administrator Jenni Gordon.