Complaint·October 29, 2025

(Continued from Page 1) HQ CPR is abbreviated for high-quality cardiopulmonary resuscitation. Fire medical services observed that R1’s passageway was obstructed with food and removed the food with forceps. R1 began to have a pulse. R1 was transported to the hospital for further evaluation and care. Based on hospital records dated July 10, 2021, medical personnel advised R1’s responsible party that R1 was “developing post hypoxic myoclonic epilepsy activity in the setting of approximately 15 minutes downtime without adequate brain oxygenation leading to likely permanent anoxic brain injury”. Hospital records dated July 12, 2021, reveal at 1740 hours, medical personnel were called to R1’s room due to R1 was “without heart rate or breathing. Pupils fixed no spontaneous heart rate no spontaneous breathing time of death 1740 hours cause of death anoxic brain injury from cardiac arrest from choking.” Information obtained from interviews revealed the following: a staff witness revealed they heard R1 coughing and gave R1 a cup of water. R1 continued to cough. The staff indicated R1 was asked if they were okay and R1 responded with their hands in a motion perceived by the staff to indicate that R1 was okay. Due to R1’s continued coughing, the staff called for Med Tech Rita Ortiz. Ortiz responded within 5 minutes, asking R1 if they were okay, to which R1 responded using the same hand motions. Ortiz then instructed the staff to stay with R1 while Ortiz left the area to call 911. It was reported Ortiz did not return to the common lunchroom until emergency services personnel arrived at the facility. Ortiz was interviewed and reported she received a call from another staff. Ortiz responded to the common lunchroom in less than one minute to assess R1. Ortiz reports R1 took a sip of water and motioned with their hands that they were okay. The staff pointed out R1 was gurgling. Ortiz instructed this staff to stay with R1 while she called 911. Ortiz contacted 911 and then started paperwork in preparation for emergency services personnel to arrive. Ortiz reports she did not think R1 was choking because R1 took a sip of water. Ortiz reports she observed R1’s face to change color but R1 was still breathing. Ortiz further reports she did not think R1 required cardiopulmonary resuscitation (CPR) because R1 was breathing and conscious. Ortiz reports that when she called 911, she reported R1 was conscious but was not feeling well. This contradicts the ABR which indicates the call came in as choking. Ortiz reports the 911 operator instructed her to call back if anything changed and to have someone watch R1. Ortiz explained the other staff was already with R1 at the time. The staff who was left to watch R1 was hired on May 20, 2021. The staff reported they had not yet had CPR or first aid training at the time of the incident. (Continued on Page 3) (Continued from Page 2) Death certificate dated September 3, 2021, revealed immediate cause of death is anoxic encephalopathy and obstruction of the airway by food. Interviews confirmed staff did not perform first aid to R1 during the choking incident. R1 exhibited signs such as coughing, turning color and gurgling. R1’s presence in the lunchroom along with the fact they were eating at the time of the incident further indicates first aid was needed. According to mayoclinic.org, choking is a life-threatening emergency because it cuts off oxygen to the brain, and therefore, first aid (abdominal thrust) should be performed immediately. The allegation that staff neglect resulted in R1’s death is substantiated. The preponderance of evidence standard has been met. The facility will be cited for violation of California Code of Regulations, Title 22, Division 6, Chapter 8, Sections 87468.2(a)(8) and 87411(a). This poses a health and safety risk to clients in care. A substantiated finding means that the allegation is valid because the preponderance of evidence standard has been met. In addition, this violation posed an immediate Health and Safety risk to resident(s) in care. An Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that a civil penalty may be assessed based on Health and Safety Code § 1569.49. An exit interview was conducted, a copy of this report, along with the 9099-D, Civil Penalties and appeal rights were provided to Administrator Rachelle Wheaton and Business Office Manager Jonathan Guzman.