Incident investigation·May 26, 2021

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced case management visit to the facility. LPA was greeted and granted entry into the facility by Administrator Stephanie Jukic and explained the reason for the visit. Director of Health and Wellness Heather Lopez was present as well. The purpose of today’s visit is to follow up on an investigation conducted by the Department. The investigation conducted revealed the following: On 02/22/2021, Resident 1 (R1) was observed by Resident 2 (R2) slumped over on the ground in front of the facility church. R2 obtained assistance for R1 due to thinking the resident was having difficulty standing up. R2 recalled hearing a loud sound but was unsure what the sound was. Staff responded and R1 was observed with a pistol in their hand and blood splatter on the resident’s person as well as the wall of the church. 911 was called and Santa Ana Police as well as paramedics responded. The Orange County Sheriff-Coroner subsequently responded as it was determined R1 was deceased. The Coroner conducted an investigation as well as an external examination of R1 and it was determined R1 was deceased from a self-inflicted single gunshot wound to the head. Through the investigation conducted, the Department was unable to discern where R1 obtained the pistol. The facility Administrator reported having no knowledge of the pistol being onsite at the facility. R1 resided in the independent living side of the facility and was receiving no assistance from facility with activities of daily living. R1 had recently returned from a skilled nursing facility on 02/16/2021 due to contracting Covid-19. Witnesses state there was no indication that R1 had any suicidal ideations, although the resident had recently questioned what happens to belongings once a resident passes and had recently sold their car. In an interview with R1’s family member, it was revealed a suicide letter was left inside the resident’s apartment stating a decline in health as a reason for the suicide. Due to R1’s status as independent, the investigation did not produce substantial evidence of neglect or lack of care by facility. No deficiencies were cited. An exit interview was conducted and a copy of this report was left at the facility.