Complaint Investigation Report

On 09/13/2023, resident (R1) was transported to the hospital after choking on a piece of pastry. During the incident, 3 staff members were present. 2 out of 3 staff members were present serving R1 and other residents with their breakfast. Based on staff interviews, as staff (S1) was preparing the food for R1, another resident (R2) gave R1 a pastry and R1 started eating it. R1 stood up and S1 noticed R1 was having a hard time breathing. S1 called S2 for help and staff (S2) then provided first aid while S1 contacted Emergency Medical Services (EMS). During the ambulance ride, R1 began to go into cardiac arrest. Upon arriving to the hospital, R1’s developed severe medical conditions. On 09/26/2023, R1 passed away at the hospital with an official cause of death being cardiac arrest.

The review of the video footage from the incident corroborated the staff members statements.

Based on staff interview, 4 out of 4 staff members stated none of the residents to include R1, had any food restrictions and history of choking on food.

The review of R1’s records shows that R1 did not have a special diet or food restrictions. R1 was able to feel self.

The Department has investigated the above allegations. Based on interview, record review, and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Naward Hernandez and a copy of the report was provided.