Incident investigation·April 9, 2025

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – incident visit. This visit is a follow-up to a case management visit conducted at the facility on 05/29/2024. LPA met with General Manager, Billy Mitchell. On 05/23/2024, the Department was informed of resident (R1)’s death that was observed by staff during morning check-ins with the residents. The Department was investigating the allegation of neglect/lack of supervision resulting in R1 committing suicide while in care. During the investigation, it was found that at approximately 0945 hours, staff checked in with R1 as R1 did not check in with the front desk by 0830 hours based on the facility’s policy. When staff entered R1’s bedroom, staff found R1 deceased inside his/her bedroom by apparent suicide. A note was found stating that R1 acted alone without any assistance. The facility staff immediately called 911. Staff members and resident were interviewed. Based on interviews, R1 never made any suicidal statements and/or had suicidal ideations. R1 was independent and did not require any kind of assistance. Based on record review of R1’s file, documents did not indicate or notate any signs of depression or suicidal behaviors. Facility staff did not provide and could not state how R1 obtained items used to aid in his/her death. Page 1 of 2. The review of the police report records indicated that there were no signs of trauma or foul play. The Department has investigated the allegation to be unsubstantiated, meaning, although the incident may have happened and/or did occur, there is not a preponderance of evidence to prove a Title 22 violation. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Billy Mitchell and a copy of the report was provided. Page 2 of 2.