Incident investigation·November 6, 2023

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management - Incident visit and met with Administrator (ADM) Shantela Yadao. On 11/06/2023, LPA Chang interviewed staff S1- who stated that Resident (R1) was found on the floor of R1's bedroom on 11/3/2023 at 7:00AM in Assisted Living found by staff (S2). 911 was called immediately, around 7:15AM on 11/3/2023. R1 was assessed by paramedics, R1 was pronounced dead at 7:25AM. LPA interviewed 4 Staff (S1 - S4) and Administrator (ADM). LPA interviewed two Family members (FM1, FM2) of resident (R1). LPA obtained R1's Physician Report, Medication list and Care Plan and notes. 4 Out of 4 staff stated that R1 was weak due to cancer and was on oxygen 24 hours due to short of breath. ADM stated that R1 was seen on 11/3/02023 at 4:50AM by a NOC shift staff (S5) in his/her bedroom and was fine. On 11/3/2023, at 7:00AM, R1 was found on the floor unresponsive of his/her bedroom. Continue on LIC809-C. Page 1 of 2. Both Family members of R1 stated R1 was getting weaker, and his/her medical/health condition was declining. Both stated they don't have any complaint against the facility; they were supposed to have a meeting with the facility and hospice care agency today, 11/6/23. This case needs further investigation. ADM will update CCL office when R1's death certificate is available. Exit interview was conducted with ADM. The report was provided to ADM for signature. A copy the report was provided to ADM. Page 2 of 2.