Incident investigation·September 17, 2024

Licensing Program Analyst (LPA) Julie Florio arrived to the assisted living building in this Continuing Care Retirement Community (CCRC) unannounced to conduct a required 24-hour Case Management - Incident visit regarding an Unusual Incident Report (UIR), received by CCL on 9/12/2024. The UIR stated a Resident (R1) did not receive their Warfarin for nine (9) days, became unresponsive on 9/9/2024, was sent to the ER, and was then transferred to UC Davis Medical Center (UCDMC). Upon telephone follow up and email communications with Kelly Yee, Assisted Living Manager, on Monday, September 16, 2024, LPA was informed the R1 passed away on Sunday, September 15, 2024 at 8:00 PM at UCDMC. Today, 9/17/2024, LPA met with Kelly Yee, Assisted Living Manager, and obtained documents, to include R1's admissions agreement and Death Report, not already received by CCL. Kelly states the facility is still waiting on R1's medical records and death certificate but will submit them to CCL upon receipt. A cause of death is still unknown by the facility at this time. At approximately 9:45 AM, Kevin Hogan, Health Care Administrator arrived and stated he "would like to be a part of this" investigation. No Deficiencies cited during visit. Exit interview conducted. Copy of report discussed and provided to Manager. Signature on form confirms receipt of documents.