Incident investigation·May 20, 2026

Licensing Program Analyst (LPA) Melissa Parks arrived on Wednesday May 20, 2026 to conduct a case management visit on an incident which was reported to the Department on April 1, 2026. LPA met with interim Executive Director Desiree and explained the purpose of the visit. On March 31, 2026 around dinner time, R1 had a choking incident. Staff observed resident was choking, slumped over and turning blue. Staff performed multiple attempts of the Heimlich Maneuver and was able to clear the blockage. Food was scooped out of R1's mouth and their color returned to baseline. Facility nurse assessed resident and was laid on their side. AMR was called and transported the resident to Sutter ER for evaluation. There was no diagnosis given on hospital discharge paperwork with instructions to follow up with primary physician. At the time of the choking incident, R1 had an order for thickened liquids and a regular diet. One 4/4/2026, the facility received a call from the hospital stating that R1 would return with orders for thickened liquids and puree diet. R1 was placed on hospice on 4/10/2026 once resident returned to the facility. LPA obtained a copy of R1's original and updated physicians report, hospital discharge paperwork, and resident notes. No deficiencies cited. Exit interview conducted. A copy of this report was provided to the facility.