Incident investigation·May 28, 2025

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced case management visit regarding a report received in our Regional Office. LPA was greeted and granted entry by Concierge. LPA met with Cynthia Figueroa, Executive Director (ED) and explained the purpose of the visit. The purpose of the visit is to follow-up on a Death Report received in our office on May 22, 2025. LPA spoke with ED and obtained copies of Resident #1 (R1)'s: Identification Form, Physician Orders for Life Sustaining Treatment (POLST), Physician's Report, Needs and Services Plan/ Appraisal, Discharge paperwork from hospital and follow-up orders. LPA interviewed the Resident Services Director (RSD) from a sister facility; who was on-site with the MedTech, who were called to R1's apartment on May 22, 2025. Both Med Tech and RSD did not detect a pulse. 911 was called and RSD grabbed POLST paperwork and noted R1 was DNR. LPA spoke with ED about the chronological order of events; as well as with the Power of Attorney (POA). POA shared palliative care was being considered with Primary Care Physician (PCP) on the day prior to R1's passing. POLST documentation states Do Not Resuscitate (DNR) but the box was also checked for Full Treatment. At time of incident, RSD showed police department (PD) the POLST and verbally stated R1 was DNR and pointed at the checked DNR box. PD felt a faint pulse and initiated CPR and pointed to the POLST form box that was selected for Full Treatment. Paramedics arrived on scene and were told R1 was DNR and contacted POA, who also confirmed R1 was DNR. The Fire Department (FD) spoke with ED Figueroa regarding the communication between the facility, PD and FD and will provide an in-service for facility staff (Continued on LIC 809-C) (Continued from LIC 809)\ regarding clear and preferred communication for first responders. Based on LPA's file review, interviews and observations, the facility is in complaince with Title 22 California Code of Regulatiosn and no deficiences will be cited on this date An exit interview was conducted with Cynthia Figueroa, ED and a copy of this report and LIC 811 was provided at exit.