Incident investigation·February 1, 2024

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with General Manager Lori Hansen. LPA also met with Resident Service Director Kelly Biondo during the visit. Today's visit was in response to licensee’s self-reported death of Resident #1 (R1), received at the CCLD San Diego Regional Office on 01/26/2024. [See LIC 811 Confidential Names List for a description of R1]. Per the report, R1 passed away on 01/20/2024. During today’s visit, LPA performed a brief facility tour and welfare check on remaining residents, finding no safety concerns. LPA also collected copies of and reviewed pertinent records and interviewed relevant staff. Per review of care records: R1 moved into the facility in May 2023. At that time, Licensee had obtained a recent Medical Assessment (i.e., an LIC602 Physician’s Report dated 04/18/2023) on R1. However, the LIC602 did not indicate whether a test for tuberculosis (TB) was performed on R1. LPA asked multiple managers if there was some other written record of R1 having a negative TB test result from the time of their move-in, but none could be produced during today’s visit. Staff interviews confirmed that R1 did not exhibit TB symptoms during their stay at the facility. Nothing in R1’s internal or external care records, which LPA reviewed today, suggested that R1 was ever infected with TB during their stay at the facility. R1 had a subsequent chest X-ray on 01/02/2024, which did not show evidence of TB. Per R1’s official Death Certificate, their death was unrelated to TB. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. LPA also issued one (1) Technical Violation (TV) regarding reporting requirements (see the LIC 9102-TV page). An exit interview was conducted with Hansen, to whom a copy of this report, the LIC809-D, the LIC9102-TV, and the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.