Incident investigation·August 13, 2024

On 8/13/24, at 2:38pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct a case management visit regarding an incident report received by the Department on 6/26/24. LPA met with Alyssa Sellers, Executive Director (ED), and stated the purpose of the visit. Incident Description: On 6/20/24, a resident in care (R1) reported to the care staff that they were being abused by their friend. R1 claimed that their friend was drugging them and attempting to kill them. R1 requested assistance to call 911 and to be transported to the hospital. Actions Taken: R1 was promptly transported to the hospital for evaluation and treatment. The police were notified and conducted a visit to the facility. Adult Protective Services (APS) and the Ombudsman were also informed and initiated their investigations. Hospital Findings: A drug test conducted at the hospital indicated the presence of opiates and fentanyl. These substances were consistent with R1’s current medications prescribed per hospice orders. Follow-Up Actions: On 6/21/24, a hospice nurse conducted a follow-up visit to adjust R1’s medications. Review of R1’s medication list from 8/25/23, confirmed the use of a fentanyl patch. R1’s Needs and Services Plan dated 4/9/24, confirmed that R1 was under hospice care due to a malignant condition. Progress and Final Outcome: Progress notes from 6/21/24, to 7/26/2024, documented ongoing hospice care and medication adjustments. R1 experienced increasing confusion due to the progression of their illness. R1 passed away on 726/24, during a hospice nurse visit. {1 of 2} Summary: The incident involving R1's report of abuse was thoroughly investigated by different agencies, and subsequent medical and administrative reviews confirmed that R1's medication use was appropriate as per hospice guidelines. The progression of R1’s condition and their eventual passing were consistent with the expected outcomes of their terminal illness and hospice care. Per California Code of Regulations, Title 22 no deficiencies were observed or cited during today's case management inspection. An exit interview was conducted with ED and Caryl Ridgeway, Management Company representive and a copy of this report was provided. {2 of 2}