complaint·February 7, 2024

Although the facility had an agreement in place with the family and resident for no room overnight checks for the resident to not disturb the resident’s dog, the department has identified the facility did not meet their own requirements of two hour room checks that should have been conducted per facility’s plan of operation. Resident left the facility at approximately 7:30pm and there were no checks on the resident after that time. Per the family and facility there was an agreement for no checks from 10:00pm to 6:00am. As a result, no staff checked on the resident to ensure their health safety or whereabouts for the resident from the time period of 7:30pm to 10:00pm which exceeds the time limit identified in the facilities plan of operation. The department has also obtained a copy of the coroner’s report regarding the death of former resident. The coroner’s determination of death for the resident is hypothermia. The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Questionable Death is substantiated. The following deficiency is cited per California Code of Regulations, TITLE 22 and an immediate civil penalty has been issued. The circumstances of this complaint are being evaluated for additional civil penalties. Exit interview was conducted with the facility Administrator. Appeal Rights were issued, and a copy of this report was left at the facility.