Incident investigation·February 11, 2025

Licensing Program Analyst (LPA) Zabel Chochian conducted a Case Management – Incident visit. Upn arrival LPA met with Executive Director (ED) Johnny Ortiz. Reason for visit was explained. The reason for today's inspection is to follow up on a self reported incident report received on 02/10/2025. The report pertains to an incident involving Resident #1 (R1) . It was reported that on 2/01/25, R1 sustained an unwitnessed fall at the facility. R1 sustained a bump on the back of the head therefore 911 was called and resident was transferred to Los Roblas Hospital ER; 02/02/2025, R1 was discharged from ER at approximately 3am. R1 was put on a 72 hour monitoring upon return from the hospital. On 02/04/2025, R1 was observed not feeling well therefore 911 was contacted and resident was transferred to ER again. On 02/06/2025, facility was notified by R1's responsible person that R1 had passed way. Per the information received, the circumstances surrounding the death of R1 on 02/06/2025 may be questionable. During today's visit, the LPA conducted interview with the ED and facility's Health Service Director-Pricila Bosdoganian; copies of pertinent documents requested including but not limited to a copy of the death certificate/report. LPA informed ED that this incident was referred to Community Care Licensing Investigations Branch (IB) for review and that further review is required. An LPA will return at a later date to issue findings. Exit interview conducted. A copy of the report was