Incident investigation·June 18, 2021

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on incident reports submitted to Community Care Licensing (CCL)). LPA identified herself and discussed the purpose of the visit with Executive Director Johanna Gonzalez. Incident report dated 05/16/2021 indicated Resident 1 (R1) became aggressive with staff and 911 was called. R1 refused to go out and psych evaluation requested. A one on one companion was placed with R1. R1 was previously evaluated ay Chapman Global Medical Center. Physician report dated 05/01/2021 indicated a diagnosis of Dementia with Psychosis and physician notes indicate R1 was suicidal. R1 moved out of the community on 06/15/2021. Death report dated 05/10/2021 indicated R2 was discovered on the floor unresponsive and without vital signs. R2 declared deceased by paramedics. Per physician report dated 04/15/2019, R2 is diabetic. R2 was prescribed Carvedilol for Hypertension, Furosemide for Congestive Heart Failure, and Eliquis as a blood thinner. Per facility, autopsy not performed as it was not requested by family. No citations noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.