Complaint·March 30, 2026

During the Department’s investigation, a comprehensive review of records and interviews with facility residents and staff members was conducted to ascertain the circumstances surrounding the incident. The Department’s review of R1’s resident file revealed that R1 always required oxygen tank and oxygen concentrator. R1 also had cognitive condition that interfered with R1’s ability to perform activities of daily living. R1’s care plan indicated that R1 required maximum assistance with special care needs, such as two (2) hour safety checks and assistance with oxygen use. The Department conducted interviews with two (2) staff members who were on duty on the night of R1’s death. Interview with both staff members revealed R1’s wellbeing was not monitored during the entire night shift. This lack of neglect and supervision was considered a contributing factor in R1’s death. Given R1’s diagnosed conditions and medical needs, regular monitoring of at least two (2) hours was a required standard of care. It is important to note R1’s body was discovered by a staff member who worked the morning shift. The Department’s investigation provided enough information to corroborate the allegation of lack of supervision/neglect resulting in death of resident. Based on interviews conducted and records review, this allegation is substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An immediate civil penalty of $500 is being assessed. In accordance with CCR Section 87468.2(a)(4), the determination of additional civil penalties for a violation that resulted in a death of resident, is pending and under review by the Department. An exit interview was conducted where a copy of this report was provided, along with LIC9099C, LIC9099D, LIC421IM, and Appeal Rights were provided.