On the night of 07/10/2025, around midnight, R1 was sitting at the kitchen table using their tablet while Staff 1 (S1) and Staff 2 (S2) were on shift. S2 left the area to use the restroom, leaving R1 under the sole supervision of S1. While S2 was away, S1 chose to leave the area and go into R1’s bedroom to find a tablet charger. S1 was aware that S2 was in the restroom at the time, meaning R1 was left completely unattended in the kitchen with direct access to the refrigerator. When S1 returned to the kitchen, S1 discovered R1 eating a hamburger bun. S1 attempted to get R1 to spit out the hamburger bun while trying to remove the bread from their mouth manually, but S1 was unsuccessful. S2 exited the restroom to find R1 still clutching a piece of the bun and struggling to breathe. Both staff members were unable to successfully perform the Heimlich maneuver, and R1 eventually turned purple and collapsed. S2 then called 911 for emergency assistance.

The Hospital medical records revealed that R1’s diagnosis listed Cardiac Arrest (Primary), Acute Respiratory Failure, unspecified whether with hypoxia or hypercapnia, Acute Kidney Injury (AKI), Hyperglycemia, and Aspiration Pneumonia. Statements from Staff 3 (S3), S2, S1, and Staff 4 (S4) confirmed that all staff members were fully aware of R1’s strict dietary restrictions. Specifically, it was well known that R1 was prohibited from consuming solid foods due to a severe choking risk.

The investigation confirmed through an interview with the S4 that this was not an isolated event, as R1 had a documented history of occasionally taking food from the refrigerator. While staff witnesses (S1 and S2) reported that R1 did not typically take food from the refrigerator, they explicitly acknowledged R1’s established habit of attempting to grab food from others due to their impulsive tendencies. Furthermore, R1’s IPP mandates continuous monitoring and constant supervision, with an emphasis on oversight during moments of potential food access. The investigation confirms that a failure in mandated supervision led to the incident involving R1. According to S4’s testimony and incident documentation, S1 left the area before their colleague, S2 returned from the restroom. This coverage gap violated the requirement for continuous, direct supervision. While R1 did not express hunger or a specific desire for food, R1’s known history of impulsive behavior made the kitchen a high-risk environment. By leaving R1 alone in that space, the staff provided R1 with unsupervised access to solid foods that posed a life-threatening risk. This lack of oversight resulted in a choking episode, a subsequent cardiac arrest, and a severe brain injury. Because the staff failed to perform a proper hand-off to ensure constant safety. The preponderance of the evidence standard has been met, and the allegation of Neglect and Lack of Care and Supervision is substantiated.

On 7/11/25, the department received a complaint alleging the questionable death of R1. On 07/10/25, the day of the incident, R1 was left unattended for approximately five minutes while one staff member searched for a tablet charger and the other was in the restroom. During this unsupervised period, R1 accessed a hamburger bun from the refrigerator. This resulted in an immediate choking episode that rendered R1 unresponsive. Although staff attempted life-saving measures, emergency responders were unable to clear R1’s blocked airway at the scene.

Medical records and the death certificate from the San Diego Medical Examiner’s Office conclude that the immediate cause of death was choking, with Trisomy 21 and obesity listed as contributing factors. The manner of death was ruled an accident. Because the facility was fully aware of his impulsive behaviors and dietary restrictions, the failure to maintain the mandated supervision directly allowed R1 to access the food that led to their death. The preponderance of the evidence standard has been met; therefore, the allegation of questionable death is substantiated.

Based on relevant interviews and records review, the preponderance of evidence has been met that the alleged violations occurred and are therefore substantiated. Pursuant to the California Code of Regulations, Title 22, Division 6, deficiencies were cited on the attached 9099-D. Pursuant to the California Code of Regulations, Title 22, Division 6, deficiencies were cited on the attached 9099-D. An immediate civil penalty of $500 was assessed during today’s visit for neglect, lack of care, and supervision resulting in a resident’s hospitalization. An immediate civil penalty of $15,000 was assessed during today's visit for the allegation of questionable death. At this time, per Health and Safety Code Section 1569.2(c), an additional civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division. An exit interview was conducted with the Administrator, and a plan of correction was jointly developed. A copy of these reports, along with Licensee/Appeal Rights (LIC 9058 03/22), was provided after the visit.