Complaint·March 19, 2026

Review of the facility’s employee schedule and interviews revealed that Staff #1 (S1) was present during the choking episode of R1. Review of S1’s personnel record revealed that S1 had an active Cardiopulmonary Resuscitation (CPR) certificate. Interviews with staff and residents did not reveal that another resident came to the aid of R1 but rather it was S1 that immediately came to the aid of R1. Based on interviews and record review, the investigation did not yield a preponderance of evidence to conclude that staff did not ensure resident received timely medical care. Based on the foregoing, the allegation is unsubstantiated. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Executive Director Gutierrez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.