Incident investigation·July 25, 2022

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced case management visit to the facility to follow up on two incidents reported to Community Care Licensing. LPA met with Executive Director Suzanne Nasraty and Resident Health Services Director Marirose Kendle and explained the reason for the visit. Safety Director Thad McKay and Safety Officer James Salilo were present as well. On 07/22/2022, Resident 1's (R1) family had contacted Wellness Department and Safety Department to request a Wellness check around 7 PM. Safety Officer responded and resident did not respond to doorbell. Safety officer made entrance into resident's apartment and observed R1 did not respond to Safety Officer. The bedroom door was closed. Safety officer was unable to make entrance into the bedroom as the door was blocked and called 911. Sheriff and paramedics responded and R1 was pronounced dead from suicide at 1955 PM. Resident had an MRI the day before for back issues. Per physician report dated 02/19/2021, R1 is independent, can leave the facility unassisted and manage own medications. Facility provides no assistance with activities of daily living. Per interview and facility medication sheet, R1 is on three medications for hypertension and high cholesterol. R1 had a prior suspected suicide attempt in February 2021 but was cleared by physician and had no medication changes. Resident had checked in with facility as facility protocol on 07/22/2022 and Health Services Director had made contact with resident at 12:29 PM same day. During the visit, LPA toured the resident's apartment and spoke with R1's family. Facility to forward a copy of the death certificate to LPA once received. On 07/20/2022, Safety Officers responded to a call of a car running in R2's garage. Safety Officer utilized the emergency mechanism to open the garage and observed R2 sitting in the car while it was running. R2 turned off the car at that time and safety officers removed the resident from the garage. 911 was called and resident was assessed to have a self inflicted superficial wound on left wrist. Paramedics cleared the resident physically and R2 was sent out to Mission Hospital on a psychiatric hold. Resident remains at Canyon Ridge Hospital for observation. CONTINUED ON LIC 809C DATED 07/25/2022. Resident has had no prior suicidal ideations and is not on any psychiatric medication. Physician report dated 10/02/2019 indicates resident is independent, manages own medications and can leave the facility unassisted. During the visit, LPA observed the garage as well as R2's apartment. During the visit, LPA toured the facility and observed residents relaxing or participating in activities. Residents were observed outside and eating lunch as well. LPA spoke with residents who verbalized satisfaction with the facility. No health or safety violations noted during today's visit. Based on the observations made during today's visit, no citations noted. Exit interview conducted and a copy of this report was left at the facility.