complaint·April 29, 2026

(Continued from 9099...) R1’s Assessment and Service Plan dated 10/10/2025, noted they had eating difficulties, had prior incidents of choking, and required supervision during meals. On the day of the incident, staff were not supervising R1 as R1 was supervised by family. Family called for help and staff (S1) responded to assist. S1 reported R1 was coughing but did not perform the Heimlich maneuver and sought emergency medical services. 911 recording was obtained and it supports S1 failed to call 911 immediately for an emergency situation and called hospice first. Further, S1 reported to the 911 dispatcher that R1 was choking and is currently having shortness of breath, can’t breathe, and their lips were turning purple. There was no mention of R1 coughing. There were no staff providing medical care to R1 while S1 was on phone with the dispatcher. Dispatcher instructed S1 to place R1 flat on their back in order to perform CPR. S1 stated, “we can’t perform CPR.” Based on the evidence, there is sufficient information to corroborate that staff failed to provide basic first-aid. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 1, is being cited on the attached LIC 9099D. Appeal rights given. An immediate civil penalty is being assessed today in the amount of $500 for a violation that resulted in the death of a resident in care. The licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f)