Complaint·April 16, 2026

Death Report LIC 624A submitted to the Department regarding R1's death states R1 passed away on February 10, 2026. Death report states "county called [spouse], who shared with [staff] that they refused to do an autopsy. They told [spouse] sense [R1's] airways were cleared, there was no need to do an autopsy." On April 2, 2026, the Department obtained R1's death certificate by mail. R1’s date of death is listed as February 10, 2026. R1's immediate cause of death is listed as cardiopulmonary arrest, with the time interval between the onset and death noted in minutes. The underlying conditions contributing to R1’s death are a history of ischemic stroke, with the time interval between the onset and death noted in months. No other significant conditions contributed to R1’s death. R1’s death was reported to the Sacramento County Coroner’s office and no biopsy or autopsy was performed. On January 14, 2026, LPA conducted a medication count for R1, comparing R1's Centrally Stored Medication Form (CSMF) and Medication Administration Record (MAR) with medications centrally stored for the resident. LPA did not observe any evidence of R1 missing medications. LPA requested medications records from January 14, 2026 to February 10, 2026. Facility was unable to provide requested medication records to LPA by April 16, 2026. LPA cited facility for records in a separate inspection report conducted on April 16, 2026. Interview conducted with resident (R2) indicated that they have never witnessed any incidents of residents being neglected at the facility. R2 stated that they have no concerns regarding medication administration at the facility, they feel their care needs are being met at the facility, and they are treated well by facility staff. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated 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. Exit interview was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.