Incident investigation·September 10, 2025

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced case management – incident visit to the facility regarding a self-reported incident and a self-reported death that occurred on 8/31/2025. LPA Kontilis met with Jade Alma, Administrator to explain the purpose of the visit. On 9/3/2025, CCLD received LIC624 Unusual Incident/Injury Report stating 9-1-1 was called on 8/31/2025 for Resident 1 (R1) when R1 was observed to have “increased confusion found eating balmex”. The incident report states Staff 1 (S1) noted “pale skin and not at baseline…upon Paramedics’ assessment resident blood pressure was very low. Resident was sent out to ER by ambulance for further evaluation.” On 9/3/2025, CCLD received LIC624A Death Report stating R1 passed away at the hospital on 8/31/2025 at approximately 3:15 PM. The death report states R1’s responsible party reported R1’s passing to facility personnel. Death Report states cause of death is “Unknown at this time…” R1 was not on hospice. Per the information received, the circumstances surrounding R1’s death may be questionable, and an investigation is required. During today’s visit, LPA Kontilis obtained documents pertaining to the investigation and conducted in-person interviews. Due to time restraints, LPA will return at a later date to continue the investigation. Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.