Community Care Licensing (CCL) has completed the investigation into the allegation that neglect and lack of care and supervision by facility staff resulted in the death of Resident 1 (R1), identified on the LIC 811 Confidential Names List.

The investigation consisted of a review of facility records, review of the Medical Examiner’s report, review of photographic evidence, interviews with staff and outside sources, and review of physician orders and dietary records.

Department records review revealed physician documentation that R1 had multiple significant medical conditions, including dementia and oropharyngeal dysphagia. Physician’s Reports dated January 26, 2024, and May 8, 2025, documented that R1 required a soft and bite-sized diet and a minced and moist diet with thin liquids. Both physicians specifically ordered that R1’s food be modified to reduce the risk of choking. These diet orders were on file and available to staff at the time of the incident.

(Continued LIC 9099C)

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

Department interviews revealed that on the night of January 1, 2026, R1 approached staff and requested something to eat. R1 was seated in a wheelchair in the hallway near the nurse station. Department interviews revealed that R1 was unsupervised at the time and that Staff #1 (S1) prepared a peanut butter and jelly sandwich for R1. S1 acknowledged that she knew R1 was on a soft diet but did not check the dietary information board posted at the entrance to the dining room. S1 reported that she considered a peanut butter and jelly sandwich to be a “soft” food and therefore appropriate. S1 provided R1 with an uncut, whole sandwich that was not minced or cut into bite-sized pieces as required by the physician-ordered diet.

According to witness statements, S1 returned to the dining hall after handing the sandwich to R1. Approximately five minutes later, S1 returned to the hallway and observed R1 with a pale face and hands to the throat, consistent with choking. Statements from staff confirm that R1 had taken a single bite from the sandwich when the choking event occurred. Staff #2 (S2) responded after hearing S1 call for help, and Staff #3 (S3) initiated the Heimlich maneuver. S3 reported that some food particles were expelled, but R1 remained unresponsive. R1 was placed on the floor and CPR was initiated until paramedics arrived. Facility staff provided paramedics with R1’s active Physician Orders for Life-Sustaining Treatment (POLST), which directed Do-Not-Resuscitate status, and paramedics subsequently discontinued resuscitation efforts. R1 was pronounced deceased at 2245 hours.

R1's death certificate issued by the San Diego County Medical Examiner lists the cause of death as asphyxia due to choking, with dementia listed as a contributing condition. The Medical Examiner’s investigation noted that a food bolus was lodged in the epiglottis and that food particles were present in both main bronchi. The manner of death was determined to be accidental. The Department incorporated the Medical Examiner’s findings and confirmed that the choking event occurred while R1 was eating the unmodified sandwich prepared by staff.

Based on review of records, interviews, photographic evidence, and the Medical Examiner’s findings, it is determined that staff failed to follow R1’s physician-ordered special diet and failed to provide appropriate supervision while R1 was eating. These failures directly contributed to R1 choking on food that was not prepared according to ordered specifications. R1’s death occurred as a result of choking on an improperly prepared food item that staff knowingly provided, and R1 was left unsupervised despite documented swallowing impairment.

Based on interviews and review of documentation, the allegation identified above is SUBSTANTIED. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. The deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and is noted on the attached LIC 9099-D. An immediate civil penalty in the amount of $500 is being assessed on an LIC 421IM for the death of R1, in accordance with Section 1548(c)(1) of the Health and Safety Code. At this time, pursuant to Health and Safety Code Section 1569.49, a civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division.