Incident investigation·November 2, 2023

Licensing Program Analyst (LPA) Christine Dolores arrived to the facility unannounced to conduct a case management – incident visit regarding an incident that occurred at the facility on 10/12/2023. LPA met with Administrator, Nicholas Inneh. On 10/26/2023, LPA Dolores was made aware of a resident (R1) who passed away. On 10/12/2023, staff noticed that R1 was choking on food and immediately called 911 and began CPR and First Aid (Heimlich Maneuvers). R1 then lost consciousness and staff began chest compressions until EMT arrived. R1 was transported to the hospital and pronounced deceased on 10/13/2023. Based on interview and review of R1’s records, R1 did not have a special diet. For dinner that night, the residents were served chicken burritos. ADM states the resident did not have any issues with swallowing food or medical conditions regarding his/her throat. ADM is not aware of any history of R1 choking on food. After the incident, the ADM immediately informed R1's case manager, conservators, and physician. The staff who provided CPR has an active CPR/First Aid Certification. ADM stated on the morning of 10/13/2023, R1's case manager arrived to the facility and informed the facility staff that R1 had passed away at the hospital. LPA requested for R1’s death certificate. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Nicholas Inneh and a copy of the report was provided.