Incident investigation·November 21, 2023

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a (24) hour case management visit, pertaining to a Special Incident Report (SIR) notification of a resident's death. On 11/20/2023, Administrator Evan Granucci contacted Licensing and spoke to LPA Angela P. who reported: "At 3:26pm, LPA (OD) received a phone call from the Administrator, Evan Granucci, and was informed that on 11/20/23 around 11:30am, resident # 1 (R1) went up to the 7 th floor, which is a common area with an outdoor veranda, moved a chair close to the fence, R1 got over the fence and jumped. The body was discovered by another resident, who later reported to the concierge. LPA was informed that the resident was receiving Hospice Services and lived in an Assisted Living (independent) area. Due to the nature of the death 911 was called and police report filed. LPA was informed that the Death and Police report will be submitted promptly". During today's visit, LPA interviewed the Administrator and obtained R1's facility records. According to the Administrator, a hour prior to the incident, R1 was seen by staff, and there were no signs of distress. R1 does not have a history of depression, or suicidal ideation; but was recently admitted to hospice 10/11/2023, for coronary artery disease . Staff found R1 outside on the ground unresponsive with no pulse. 911 was called and R1 was pronounced deceased. The Ventura County police department were contacted; who visited the facility, the same day of the incident and reviewed facility surveillance. It was observed R1 used a facility chair and climbed over the railing from the 7th floor. The police deemed the incident as a suicide and no foul play. It was also reported that there were no witnesses by staff or residents of R1 falling from the 7th floor. Based on today's interview and documentation received, LPA has determined, no further action is needed at this time, and due to the police deeming no foul play. Police report # 23-75173 Exit interview and copy of report provided.