Facility Evaluation Report

08/04/2026 112:20 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Julie Wilcox. Today’s visit is regarding an incident that occurred on 07/24/2026.

It was reported that on 07/24/2026 at 6:30am Staff 1 (S1) was waking residents up for breakfast and found Resident 1 (R1) in bed unresponsive. S1 notified the house manager and 911 was called immediately. CPR was not performed as R1 had passed away several hours previous which was confirmed by EMS at 06:45 AM. Law enforcement deemed the death as non-suspicious.

During the course of the investigation, it was learned that on April 4, 2026 R1 had been hospitalized for a gall bladder infection. R1 was initially treated at a local hospital, subsequently transported to Dignity Health Sacramento, and was then transported to Stanford Hospital for surgery and treatment. R1 was in Stanford Hospital for approximately 2 weeks. On 04/17/2026 R1 came back to the facility with orders for home health. Within 72 hours R1 complained of feeling unwell and was transported back to the local hospital and then back to Stanford Hospital for treatment

On 05/01/2026 R1 was admitted to skilled nursing. R1 remained in skilled nursing for 6 weeks to receive IV antibiotic treatments and rehabilitation. R1 was discharged back to the facility from skilled nursing on 07/06/2026 with orders for home health assistance. The skilled nursing facility deemed R1 medically cleared to return to the facility. R1 had seen their primary care physician on 07/15/2026 with an order to start seeing a cardiologist on 07/28/2026 for an echocardiogram and a follow-up appointment was scheduled for 07/29/2026 for a follow-up appointment with their primary care physician.

It was determined that the facility made all appropriate arrangement for R1 to seek medical treatment when they initially started feeling unwell and for all subsequent medical appointments prior to the death of R1.

No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to administrator Julie Wilcox.