Complaint·October 2, 2025

An incident report submitted to CCLD regarding the circumstances of R1's death indicated that first responders estimated R1's time of death as some time "earlier that morning" based on R1's body temperature and the rigor mortis present in R1's body. LPA Moleski reviewed R1's care plan, dated 1/6/25. R1 was required to have checks every two hours, per the care plan. R1's appraisal, dated 1/6/25, indicated that R1 required special observation and/or night supervision. The appraisal was signed by Sylve on 1/6/25. LPA Moleski reviewed witness statements taken by facility staff regarding R1's death. Staff members who observed R1 on the evening of 1/28/25 indicated that R1 appeared normal, and was observed sitting up. An overnight caregiver on duty assigned to R1's care (S10) said in a statement that they had given water to R1 around 11 p.m. on 1/28/29, and passed by R1's room again around 2 a.m. and saw R1 asleep. Witness statements do not indicate that any additional contact was made with R1 until R1 was found unresponsive by housekeeping staff in the morning. In a statement, one staff member who alerted first responders to R1's condition (S11) said EMTs estimated R1 had died "during the overnight hours based on [R1's] physical state." LPA Moleski reviewed R1's call button responses and observed R1's last call for assistance was just before 11 p.m., presumably when S10 provided R1 with water. In an interview, Sylve said that, based on witness statements, the last time R1 was checked on was at 2 a.m. The department has determined the following as it relates to the allegation that facility staff are not checking on residents during their shifts: Based on interviews and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Section 87466. An exit interview was held with Sylve. A copy of this report and appeal rights were left with Sylve. Although R1's death was reported to the local coroner's office, no autopsy or biopsy were performed, and R1's death certificate did not indicate the death was suspicious. LPA Moleski reviewed witness statements taken by facility staff regarding R1's death. Staff members who observed R1 on the evening of 1/28/25 indicated that R1 appeared normal, and was observed sitting up. An overnight caregiver on duty assigned to R1's care (S10) said in a statement that they had given water to R1 around 11 p.m. on 1/28/29, and passed by R1's room again around 2 a.m. and saw R1 asleep. Witness statements do not indicate that any additional contact was made with R1 until R1 was found unresponsive by housekeeping staff in the morning. The department has determined the following as it relates to the allegation of a questionable death: Based on record review, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited regarding the above allegation. An exit interview was held and a copy of this report was left with Sylve.