Incident investigation·December 12, 2024

On 12/12/2024, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to this facility to conduct a case management visit regarding a death incident. LPA met with the Assistant Administrator Susan McClure and stated the purpose of this visit. The Regional Office (RO) received a death report for resident (R1), who was reported to have passed away on 10/15/2024. Facility staff (S1) reported that R1 was found unresponsive on the floor of their room with no pulse. CPR was provided until paramedics arrived and continued CPR until R1 was pronounced dead at 8:42 AM. Prior to being found on the floor, R1 had been sitting in their chair. An investigation was conducted by the Department, focusing on the review of the death certificate. The death certificate listed cardiac arrest as the immediate cause of death, with the following contributing health conditions: C1 and C2. It was noted that no autopsy or biopsy was performed. The investigation concluded that there were no signs or indicators suggesting that R1's death was questionable. Per the California Code of Regulations, Title 22, no deficiencies were cited during this visit. An exit interview was held with Susan McClure, and a copy of this report was provided.