Complaint Investigation Report

374603509-11-10-2025-08-AS-BCHN-DND3FW-20251112171324

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

SAN DIEGO RO , 7575 METROPOLITAN DR. #109

This is an official report of an unannounced visit/investigation of a complaint received in our office on

03/18/2025 and conducted by Evaluator Grace Donato

COMPLAINT CONTROL NUMBER: 08-AS-20250318135957

On 11/10/2025, LPA Grace Donato conducted a telephone interview with the facility to deliver findings. LPA spoke with Business Office Director Ellen Arguello and explained the purpose of the call.

Regarding the allegation of questionable death, reporting party (RP) stated that aspiration occurred due to routine medications being given to the resident by facility staff (not hospice) which led to aspiration pneumonia and the death of the resident.

R1 was under hospice care. Facility staff were following doctors’ orders in administering medication. On 2/16/2025, around 12:41pm, facility received fax from doctor to discontinue medication. On the evening of same date, other medications were administered. R1 was routinely checked until passing on 2/17/2025.

Death certificate did not indicate that R1 passed due to aspiration pneumonia.

Based on records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.