Incident investigation·October 8, 2025

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – incident visit. The purpose of this visit is to deliver the final report on a case management that was initiated on 09/19/2025 regarding a death report received on 08/12/2025 for former resident (R1). LPA met with General Manager, Ida Gemignani-Stearns. On 08/12/2025, the Department received a death report stating that on 08/11/2025 at approximately 09:30am, a staff went to give R1 medications and found R1 unresponsive. In the report, it was stated that the resident was noted to have some confusion on 08/08/2025 and 911 was called but resident refused to be transferred for further evaluation. 4 staff members were interviewed. Based on staff interview, R1 was not under hospice care and resided in assisted living. R1 was only receiving medication management and housekeeping once a week but was independent for other care needs. According to the staff, the last time R1 was checked was during the night before his/her passing during bedtime medication pass. Since R1 wasn't a resident who required care, staff were not required to check R1 throughout the night unless R1 called for assistance. Staff members who observed R1 that night before his/her passing did not report anything unusual with R1’s condition. R1’s responsible party was interviewed. Based on the interview, it was stated that R1 had many health conditions which may have contributed to his/her passing. It was stated that leading up to R1’s passing, R1 was already not feeling well but refused to go to the hospital. Page 1 of 2. R1’s responsible party stated that the facility responded right away and called 911 upon discovering R1. R1’s cause of death is unknown at this time but R1’s responsible party does not feel there was any foul play or neglect from the facility. Based on record review, R1 had multiple health conditions. Facility staff noted the observation of R1 not feeling well on 08/07/2025. Staff tested R1 for COVID and the results were negative. R1 did not report any pain. The review of records show that R1 was monitored the next day and no changes of condition was noted. Based on R1’s care plan, R1 did not require any assistance with activities of daily living to include bathing, dressing, grooming, transferring and toileting. Based on R1’s responsible party, the cause of death based on the certificate is unknown as of 09/19/2025. No further follow-up needed at this time, unless new information is presented in the future that warrants this case to be re-opened. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager, Ida Gemignani-Stearns and a copy of the report was provided. Page 2 of 2.