Incident investigation·April 21, 2023

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by and identified himself to Concierge Thea Koulouras. LPA then met and discussed the purpose of the visit with Director of Resident Care Services Zachary Striplin, RN. Today's visit was in response to an LIC624 Incident Report (received on 03/20/2023) and to an LIC624A Death Report (received 03/22/2023), both involving Resident #1 (R1), which licensee self-submitted to the CCLD San Diego Regional Office. [See LIC811 Confidential Names List for a description of R1.] Per these reports, R1 had an unwitnessed fall on 03/15/2023, combined with chest pains. R1 was transported via 911 to the hospital, where they passed away later that same morning. During today’s visit, LPA briefly toured the facility, reviewed relevant records, and interviewed pertinent staff. Per their official Death Certificate, R1's cause of death was "hypertensive and atherosclerotic cardiovascular disease." There was no indication of R1's fall being a contributing factor to their death. The evidence shows that staff timely responded to and arranged medical care for R1's cardiac symptoms. No deficiencies were identified or cited during today's visit. An exit interview was conducted with Striplin, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.