Incident investigation·August 21, 2024

Licensing Program Analyst (LPA) Lydia Martinez conducted an unannounced Case Management to follow up on an Incident that occurred on 8/17/2024. LPA met with Licensee Tricia Pedroza and reason for visit was shared. Administrator (AD) Ephantus "Epi" Warui arrived shortly after. AD submitted LIC624A to the Regional Office (RO) email address on 8/18/2024 (copy of sent email receipt provided). RO received LIC624A on 08/20/2024. According to the report: Resident 1 (R1) was found by Staff in R1's closet with a wire hanger around R1's neck unresponsive. Based on interviews with staff, R1 was found unresponsive approximately at 07:15 am by a Housekeeper; Housekeeper reported the incident to LVN who immediately called 9-1-1. LVN began CPR per 911 Dispatcher's direction until Emergency Personnel arrived. Fountain Valley Police and Paramedics arrived, assessed R1 and pronounced R1 deceased. AD Warui and family were contacted and apprised of the incident. Orange County Coroner's office picked up the body. LPA toured the facility and reviewed R1's file. LPA was provided with a copy of R1's Physician's Report dated 6/05/24, Preplacement Appraisal dated 6/6/24, Resident Appraisal dated 6/30/24, and Individual Service Plan dated 6/12/24. LPA also obtained copies of Personnel Report and Resident Roster. LPA requested a copy of the death certificate and/or coroner's report to be submitted to CCL when available. Based on file review, observation and interviews, R1 was evaluated to need minimal assistance and was independent with the exception of R1 having medication management and care assistance when needed. No deficiencies were observed during todays visit, an exit interview was conducted with AD Warui and copy of this report was emailed at the end of visit.