Incident investigation·July 14, 2025

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced case management incident visit regarding a death on 6/25/2025. LPA met with Administrator Tyler Barnes and explained the purpose of the visit. During today’s visit, LPA obtained documents and conducted in-person interviews. On 7/7/2025, the facility submitted a death report for Resident 1 (R1) who passed away on 6/29/2025 at the local hospital. The death report stated the resident was ‘admitted to ICU on 6/25/2025, awaiting official cause of death’. At 1:16 PM, LPA spoke with Administrator Barnes who stated 9-1-1 was called for R1 when R1 sustained a fall in the facility. LPA conducted a tour of the facility including the location where R1’s fall occurred. Administrator Barnes stated on 6/30/2025 at approximately 11:00 am, R1’s Power of Attorney (POA) notified the facility receptionist that R1 passed away at the hospital in the evening of 6/29/2025. Documents obtained revealed R1 has sustained multiple falls while residing in the facility. Documents obtained further revealed the facility failed to report several of R1’s fall incidents, including R1’s fall on 6/25/2025. Due to time restraints, LPA will return at a later date to continue the investigation. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 809-D). Exit interview conducted. Copy of report and appeal rights issued at the time of the visit.