Incident investigation·May 3, 2024

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management – Incident visit to the above facility. The LPA met with Administrator Matteo Digrigoli and Assisted Living Director Dee Dee Heninger explained the reason for the visit. The reason for today's inspection is to follow up on a self reported death report received on 05/01/2024. The report pertains to the death of Resident #1 (R1). Per the report received, R1 was involved in a collision with a vehicle while on their motorized scooter on 04-27-24. Emergency services and law enforcement were called to the location where the collision took place. R1 passed away on 04/28/2024 in the hospital. During today's visit, the LPA conducted interviews with the administrator, two (2) staff, one (1) resident, conducted a file review and obtained copies of pertinent documents. Interviews revealed that R1 was independent and that it was not unusual for R1 to often times leave the facility independently. Additionally, staff interviews revealed that they had not observed any change in condition since R1 was admitted to the facility. File review revealed that according to R1's last LIC 602 Physicians report R1 was independent and could leave the facility unassisted. According to R1's Care Plan, R1 was a assisted living resident admitted on 04/16/2022, R1 did not need assistance with any of their ADL's. Furthermore, R1's last appraisal dated 01/15/24 stated that R1 was active, independent, and did not require any personal help. No Citations were issued during today's visit. Exit interview and copy of report printed for Administrator.