Incident investigation·July 1, 2021

Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced case management visit and met with the Executive Director (ED) Radhika Singh. The purpose of the visit was to gather additional information as Community Care Licensing Division received a death report on 06/30/2021, of a resident (R1) who passed away on 06/27/2021. The death report indicated that R1 was committed suicide when R1 was found unresponsive by the staff in R1's room in the facility. 911 was called. Paramedics arrived moments later to pronounce R1 dead. LPA interviewed staff. R1 was alert and was able to conduct self-care. Staff took action to get R1 socialize with other residents and to participate in the events in the facility. Staff had communications with R1's primary physican and family. There was no sign of R1 expressing the suicidal idea. LPA received R1's physician's report, medical lists, needs and services plans, and communication documents. LPA requested a death certificate of R1 when it becomes available. No deficiency was cited during visit. This report was reviewed with ED and a copy of this report was provided.