Incident investigation·November 9, 2022

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator Debbie Gonzalez. The purpose of the Case Management visit was to obtain further information regarding the death of resident R1. The Department received the Death Report on 11/04/2022. R1 had a fall in R1's living unit. Facility staff did not witness the fall. However, the resident had a video camera installed in the bedroom that recorded the fall. The Death Report states that the fall contributed to R1's death. During visit, LPA Marrufo reviewed video recording of the fall and obtained timestamp information regarding the time of the fall and facility staff response time. R1 had triggered R1's emergency pendant after the fall. The timestamp information states that staff entered R1's room to respond to the fall approximately 2 minutes after the fall. LPA Marrufo obtained copies of R1's Physician's Report. The staff who responded to the fall were not present during visit. LPA Marrufo obtained the contact telephone numbers for 6 staff who responded to the fall. No deficiencies were cited at this time as per California Code of Regulations TItle 22. This report was reviewed with Administrator Debbie Gonzalez and a copy of the report was provided.