Incident investigation·April 18, 2025

Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management investigation and met with Administrative Assistant Charito Santos. The purpose of this case management visit is to follow up on a self reported death report submitted to Community Care Licensing (CCL) dated 4/17/25 involving resident (R1). LPA is following up on this death report due to R1 was not receiving hospice services when they unexpectedly passed away on 4/15/25. Per death report, “on 4/16/2024 at approximate 8:45pm staff (S1) found R1 unresponsive. According to the report, most of the residents were in bed sleeping already, no one saw R1 walking or know what happened to R1 prior to their death. The facility contacted immediately 911, paramedics arrived and declared deceased. Santa Rosa Police Department were notified (SR25-4423)”. During today's visit, LPA conducted interviews with staff, requested documentation regarding R1's health condition prior to their passing. LPA's review of R1's physician's report (LIC602) indicates that R1's had auditory challenges and had the capacity to care for themselves, their diagnosis was sepsis secondary to community acquired pneumonia and acute hypoxic respiratory failure. LPA obtained R1's Needs and Services Plan (LIC625) supports physician's diagnosis. R1's care notes did not indicates any additional information that could lead to the reason of R1's decease. Based on interviews with staff there is no indication that they noticed anything unusual prior to R1's unexpected decease. According to Administrative Assistant, R1 had a heart attack and that this was probably the reason for R1's passing but they were not sure. LPA requested the facility to obtain R1's Death Certificate and provide to CCL once received. LPA clarified that R1 passed away on 4/15/25 and not 4/16/24 as stated on the death report. Administrative Assistant stated there was a typing error when preparing the death report. No deficiencies cited during today's visit. The Department will review information obtained to determine if further actions are needed. Exit interview conducted with Administrative Assistant and a copy of this report was given.