Facility Evaluation Report

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent Case Management – Incident visit at 9:55 a.m., The LPA met with Executive Director (ED), Remon Pagels and explained the reason for the visit. Entrance interview conducted.

The Department received a self-reported incident report and a subsequent incident death report regarding Resident #1 (R1) on 05/12/2025 and 05/13/2025. Incident report indicated that on 05/11/2025 at approx. 9 a.m. Staff #1 (S1) called the front desk for assistance as they saw R1 on the floor in the parking lot on their way into work that morning. S1 and Staff #2 (S2) went to assist R1 and R1 was bleeding from the head and 911 was called. Paramedics informed staff to lay R1 on their back. At this time S1 and S2 noticed a firearm in between R1 legs / crotch area. Paramedics arrived on scene and transported R1 to the hospital. Police arrived on scene and conducted their investigation. Family and primary care physician notified.

On 05/13/2025 LPA's Mosley and Kelly Dulek conducted the initial unannounced visit. During the visit LPAs conducted a physical plant tour to ensure there were no immediate health and safety concerns, conducted an in-person interview with the ED, a file review for R1 along with obtained copies of pertinent documents relevant to the incident. On 05/27/2025 LPA Mosley requested the related police report from Ventura County Sheriff’s Office (VCSO) and received the report on 06/05/2025. On 06/04/2025 LPAs Mosley and Dulek conducted a subsequent visit. During the visit LPAs conducted a physical plant tour to ensure there were no immediate health and safety concerns, conducted in-person interviews with the ED, six (6) staff, attempted three (3) resident interviews, conducted two (2) resident interviews along with obtained copies of pertinent documents relevant to the incident.