Incident investigation·October 27, 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) on 10/18/2021 and 10/26/2021. LPA identified herself and discussed the purpose of the visit with Executive Director Johanna Gonzalez. Incident report dated 10/17/2021 indicated that Resident 1 (R1) was found on the roof of the community. R1 had crossed over via the roof top terrace. R1 was on edge of roof stating wanting to end the resident's life. 911 was called and first responders were able to safely remove resident from roof. R1 was transported to Hoag Hospital and placed on a psychiatric hold. R1 remains hospitalized to date. Physician report dated 07/23/2019 indicates R1 has a diagnosis of Major Depressive Disorder and was receiving psychotherapy. This is R1's second attempt to end the resident's life. R1 is currently prescribed Latuda 80 mg for Bi-Polar and Quetiapine Fumarate 25mg for Major Depressive Disorder. Upon discharge from hospital, R1 will be re-evaluated for suitability in the facility. During the visit, LPA, toured the roof top terrace and observed the area the resident was found. R1 moved a patio table to the wall and hoisted up over the wall. The wall was observed to be high and not easily accessed. Facility to keep LPA informed regarding R1's admission back into the facility. Incident report dated 10/25/2021 indicated two residents got into an altercation. R2 approached R3 stating the resident was going to put arsenic in the resident's coffee. R3 became frightened and grabbed a butter knife to intimidate R2. Staff intervened and the two were separated. No contact was made between residents and no injuries noted for either resident. Newport Beach police were called and declined to take a report due to the nature of the incident. No further action required. Exit interview conducted and a copy of this report was left at the facility.