Incident investigation·March 14, 2024

On 3/14/24, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced case management visit to follow up on the death report of a resident. LPA met with Medication Technician Erisa Jonathan and explained the purpose of today’s visit. The purpose of this case management visit is to follow up on a death report the Department received on 3/8/2024. According to the report, caregiver discovered resident (R1) was on the floor when doing rounds at 6:14am on 3/5/2024. Resident reported to staff that they were having difficulty breathing. 9-1-1 was called and upon their arrival resident has stopped responding. Paramedics performed CPR but when resident didn't respond they pronounced resident dead at 7:14am. LPA Truong conducted file review for former resident and obtained resident’s pertinent documents. LPA could not interview staff who first discovered R1 as they were not present at the time of visit. Facility administrator and assistant administrator have left for the day; therefore, no additional information was gathered. Per the California Code of Regulations, Title 22, no deficiencies were cited during this visit. LPA will return at a later date to complete the investigation. Exit interview was conducted and a copy of this report was left at the facility.