Follow-up·April 9, 2025

Licensing Program Analysts (LPAs) Kevin Gould and Cynthia Tamayo conducted an unannounced case management visit at facility on 4/9/25 to conclude the investigation of the Resident 1’s (R1) death that occurred on 1/4/2024. LPAs Tamayo and Gould met with facility staff, Rabindar Singh and Assistant Administrator, Susan McCloure and together discussed the investigation details. On 4/3/2025, the department obtained a copy of R1’s death certificate from the Sacramento County Office of Vital Records. R1’s date of death is listed as 1/4/2024, and the cause of death is hanging. There were no other significant conditions contributing to his death. Multiple staff denied R1’s made prior attempts to commit suicide, had any changes in behavior, or verbalized any comments to suggest that R1 was going to take their own life. Medication Technicians stated they administered R1‘s medications. R1’s medication records documented he was receiving his medication as prescribed. The Department investigations revealed multiple staff interacted with R1 earlier that day and did not notice any changes in his behavior or anything concerning before R1's death. Staff conducted client rounds every two hours and R1 did not require an additional level of supervision. Multiple staff reported it was not unusual for R1 to spend time outside during the day. Report Continued on LIC 809-C Based on the interviews conducted during the investigation process, records review, video footage, and statements obtained during the investigation process, the department did not observe any violations of Title 22 regulations. There are no deficiencies observed or cited during today's inspection. Exit interview was conducted with facility staff and a copy of this report was left at the facility.