Follow-up·August 20, 2021

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Jayden Bettencourt, Wellness Director. On 05/28/2021, the Department received a death report from the facility regarding resident R1’s death from self-inflicted gunshot wound. The Department conducted an investigation of neglect and lack of supervision resulting in R1’s death from a self-inflicted gunshot wound. The Department interviewed 6 facility staff and 1 resident and reviewed records. Interviewed staff stated resident R1 always appeared cordial with care staff, did not complain, and did not show any indication that R1 was depressed or wanted to commit suicide. R1 did not require multiple checks in a day. R1 preferred to stay in R1’s room, and staff encouraged R1 to come out of R1’s room and join activities. Needs and Services Plan and physician’s report were reviewed. Needs and Services Plan dated 03/20/2021 indicated R1 does not need safety checks. Physician’s report dated 08/11/2017 indicated R1 does not have any suicidal behavior. No deficiencies were cited as per California Code of Regulations Title 22. Based on the Department’s investigation through interviews and record reviews, the Department has found that the investigation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. This report was reviewed with Jayden Bettencourt and a copy of the report was provided.