Facility Evaluation Report

Licensing Program Analyst (LPA) Kelly Dulek conducted a case management visit with the purpose of continuing the investigation into a self-reported incident/death report. LPA arrived at the facility at 09:28AM and was greeted by front desk staff. LPA met with Executive Director (ED) Remon Pagels shortly after the visit began. Entrance interview conducted.

An incident report and separate death report were received at the Woodland Hills Regional Office on 12/16/2024. Incident report indicated that on 12/15/2024, resident’s family member called the front desk asking for staff to check on Resident #1 (R1). Caregiver went to check on R1 and found R1 “passed away by taking [R1's] own life.” Caregiver called med techs, 9-1-1 was called and ED was contacted. LPA called ED and requested relevant facility documents for R1, including care plan and physician’s report. LPA requested the related police report from Ventura County Sheriff’s Office (VCSO.) LPA received the facility documents on 12/17/2024. The death investigation was referred to Community Care Licensing Division (CCLD)’s Investigation Branch (IB) and was assigned to Investigator Dennis Douglas. Investigator Douglas obtained relevant medical records for R1 and conducted both in person and telephonic interviews with staff, residents, and other relevant parties on the following dates: 01/03/2025, 02/07/2025, 02/18/2025, and 02/19/2025. LPA Dulek then reviewed all documents provided by the facility and IB Investigator. The following was then determined:

Record review revealed that R1 had lived in the facility since 07/28/2018. According to facility staff, R1 served as a “facility ambassador” and was typically very social amongst the facility residents and potential new residents. R1 was described by ED as “independent;” incident report indicates R1 was not on care plan, medication management, or status check. Physician’s report signed on 06/14/2019 indicates R1 was able to Report Continued on LIC 809-C