Incident investigation·October 2, 2024

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator Peter Morris. The purpose of the visit was to follow up on a Death Report submitted to the Department on 05/21/2024. The Death Report stated that resident R1 was found deceased on 05/20/2024 at approximately 08:00 AM. The Death Report stated that R1 had complained of neck pain as well as having experienced vomiting and a headache at 12:01 AM on 05/20/2024. The Death Report states R1 was offered to call 911 but R1 refused. R1 was observed deceased in R1's bed at around 08:00 AM. During today's visit, LPA Marrufo interviewed staff S1 and S2. S1 stated to have received a call from R1's spouse on 05/20/2024 stating that R1 appeared deceased. S1 stated to have entered R1's living unit and observed R1 to be laying on R1's bed with R1's feet touching the floor and R1's back resting on pillows and blankets. S1 stated 911 was called and firemen, paramedics, and police arrived. S1 stated police approved of the removal of R1's body from the facility. S2 stated during interview that the facility has not received a coroner's report. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Peter Morris and a copy of this report was provided.