Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on a death report submitted to the department on 12/16/2025. LPA was greeted and granted entry into the facility and explained the reason for the visit.

Death report dated 12/15/2025 indicated Resident 1 (R1) was having difficulty breathing and 911 was called. EMS arrived and performed CPR for approximately 20 minutes before declaring the resident deceased. Garden Grove Police Department responded as well. Per physician report dated 09/27/2025, R1 was diagnosed with Hemiplegia and Hemiparesis following Cerebral Infarction, Dysphagia following Cerebral Infarction, Obesity, Pleural Effusion, Atrial Fibrillation, Neuralgia and Neuritis. Resident had been admitted to a skilled nursing in May 2025 for the above diagnosis' as well as Hypertension Urgency. Resident was prescribed multiple medications for blood pressure management. Licensee to forward a copy of the death certificate to LPA upon receipt.

During today's visit it was revealed that there had been a change in Administrator as the former administrator left on 10/24/2025. The new administrator was hired 11/03/2025 and there was no notification to the department.

Based on the observations made during today's visit, the following violation is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.