Incident investigation·September 8, 2023

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to follow up on a Death Report (LIC624A) received by the Regional Office. LPA was greeted by, identified herself to, and explained the purpose of the visit to Executive Director Wesley Lavender. On 8/23/2023, Resident 1 (R1) notified facility staff that R1 had fallen and been injured. [Executive Director was provided with a copy of the LIC811 Confidential Names List to identify R1] Facility staff assessed R1 and called for emergency services. R1 was transported to the hospital and was pronounced deceased on 8/24/2023. The facility submitted the Death Report (LIC624A) for R1 to the Department on 9/7/2023. During the visit, LPA observed residents in care, reviewed and obtained copies of facility records, and interviewed the Executive Director. No immediate health or safety concerns were observed during the visit. Interviews with the Executive Director and review of reports received by the Department revealed that the facility did not submit an Incident Report (LIC624) for R1's fall on 8/23/2023. The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC809-D page. An exit interview was conducted with Executive Director Wesley Lavender, whose signature below confirms receipt of a copy of this report, the LIC811, and the Licensee Rights (LIC 9058 01/16).