Incident investigation·July 9, 2025

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit and met with Administrator (ADM) Jasmine Latu. On 7/8/2025, the Department received a death report regarding a resident R1. On 7/9/2025, LPA interviewed ADM. ADM stated resident R1 moved in the facility memory care unit room #206 on 5/16/2025. ADM stated R1 is not on hospice care. ADM stated R1 lives in a single room and without 1:1 private caregiver. ADM stated on 7/3/2025 early morning around 3:24AM, NOC shift caregiver S1 and Memory care Director (S2) were in command station area in memory care unit. ADM stated S1 and S2 heard a big bang. S1 and S2 searched for the source of the big noise, and found R1 was on the floor near the kitchenette in R1's room. ADM stated S1 and S2 called 911 immediately, and R1 was sent to hospital. ADM stated S1 and S2 notified R1's family. ADM stated on 7/6/2025, the facility received a notice from R1's family that R1 died around 7:45AM on 7/6/2025, Sunday, in hospital. FM stated R1's cause of death is internal brain breeding. ADM stated R1 has the disease specified in the physician report dated 4/30/2025. ADM stated on 7/5/2025, R1's family (FM) told him/her the hospital doctor told FM that R1 needs surgery for the internal brain bleeding, but R1 was too weak to go through the surgery. The hospital doctor stated R1 cannot survive more than 24 hours if R1 does not receive the surgery for internal brain bleeding. LPA requested R1's physician report, appraisal needs and service, unusual incident report, and internal incident report. Continue on LIC809-C. Page 1 of 2. LPA interviewed staff NOC shift caregiver S1 and Memory care Director S2. Both stated on 7/3/2025, around 3:24AM, they were in the memory care unit and heard a big bang. They went to resident R1's room and found R1 was on the floor near the kitchenette in R1's room. S1 stated he/she observed R1 had bleeding on the right arn but did not see bleeding on R1's head. S1 called 911 immediately and S2 prepared R1's red folder. R1 was sent to hospital. S1 called R1's family and left message, and notified the facility nurse and ADM. Both S1 and S2 stated this is R1's first fall incident. ADM stated the facility sent R1's incident report to CCL office on 7/3/2025 and R1's death report to CCL office on 7/8/2025. This case needs further investigation. Exit interview was conducted with ADM. The report was provided to ADM for review and signature. A copy of the report was provided to ADM.