Incident investigation·November 8, 2021

Licensing Program Analyst (LPA), Kathrina Chin made an unannounced site visit as case management- incident as a follow up to an incident report dated 11/03/2021. LPA Chin identified herself and met with Lita Spicer, Wellness Director and Veronica Romero, LVN. LPA explained that the purpose of this visit is to obtain information regarding the death of R1 which occurred on 11/1/2021 at 6:53 AM at this facility. R1 pressed the pendent at 6:15 AM and the caregiver responded right away within 3 minutes per the SARA tracking system. Resident was not on hospice or home health. The caregiver(S1) reported to Veronica Romero, LVN that resident 1 was breathing but not waking up. Ms. Romero asked another caregiver (S2) to get her vital signs and there were none. Ms. Romero called 911 emergency personnel at 6:27 AM when S2 asked Ms. Romero to dial 911. Ms. Romero called the responsible party of R1 after she called the paramedics. The paramedics arrived and started CPR. The paramedics pronounced R1 who passed away at 6:53 AM and the paramedics called the Sheriff's Department. Ms. Romero said that she also called the Sheriff's Department to confirm and the Sheriffs arrived at approximately at 7 AM. Deputy C. Briggs #9502 provided a case number to the facility and informed Ms. Romero that the case was closed and that the Coroner's will release the body. Ms. Romero said that she called the family for the second time that the body was being released and will call the Cremation Society of Los Angeles for pick up. LPA Chin requested several documents of R1 such as physician's report, Needs and Services plan, medication list, pre-admission appraisal and POLST. No deficiency cited this review as per Title 22 of the California Code of Regulations. An exit interview was conducted with Linda Spicer, Wellness Director and a copy of this report was provided.