Incident investigation·December 14, 2021

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to follow up on events which licensee self-reported to the Community Care Licensing San Diego Regional Office (RO). LPA was welcomed by and identified himself to receptionist Arlene Ballow. LPA then met and discussed the purpose of the visit with Executive Director Mark Alsop. On 12-13-2021, the RO received an LIC624 Unusual Incident Report and an LIC624A Death Report, both regarding Resident #1 (R1) [see LIC 811 Confidential Names list for a description of R1]. The reports said that on the night of 12-07-2021, R1, who has dementia and used a walker, was found on the floor of their bathroom with head trauma and without a pulse. (R1 was last seen by staff 2 hours before, in bed). 911 was called and facility staff rendered chest compressions, but first responders pronounced R1 deceased at the facility. During today’s visit, LPA, briefly toured the facility and performed a welfare check on residents in care. LPA also obtained copies of pertinent facility care records. At the present time, the case requires further investigation. Possible follow-up telephone calls and/or visits are necessary. No deficiencies were cited on this date. An exit interview was conducted with Alsop, to whom a copy of this report, the Confidential Names list (LIC 811), and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail.