Incident investigation·October 14, 2025

Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced case management visit to the facility to conduct a health and safety check for an incident that was reported to the Regional Office. LPAs explained reason for visit and was greeted by staff on duty. For this visit, there are a total of 381 residents in care. LPAs met with Executive Director (ED) - Jennifer Suckiel and Health and Services Director (HSD) Anyeli Coleman. On October 13, 2025, the Regional Office received a death report dated for October 09, 2025 for resident 1 (R1). R1 lived in the independent living portion of the facility, and was found unresponsive by staff on duty during the routine morning daily-check ins on October 09, 2025. Per R1 physician report, R1 is able to manage their own medications, and had a pre-existing cancer diagnosis prior to death. Facility disclosed that the daily morning routine consists of residents pressing their "check-in button" between the hours of 6:15AM-10:15AM, then from there, a report is formulated, and per review, whichever residents did not press their check-in button, a nurse will physically go to their room to conduct a welfare check. On October 09, 2025, R1 failed to press their button, therefore nurse on duty (S1) conducted a check on R1 and observed resident to have passed away. Facility contacted R1's responsible party, sheriff's department, coroners office, and 911. Sheriffs department and paramedics confirmed R1's death on the spot. For this visit, no health and safety concerns were observed. For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued. An exit interview was conducted with ED Suckiel and HSD Coleman. A copy of this report was provided and explained.