Facility Evaluation Report

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent Case Management – Incident visit at 10 a.m., The LPA met with Executive Director (ED), Remon Pagels and explained the reason for the visit. Entrance interview conducted.

Community Care Licensing Division (CCLD) received two (2) self-reported incident reports and a subsequent incident death report regarding Resident #1 (R1) on 12/12/2025, 12/14/2025 and 01/08/2026. Incident report indicated that on 12/12/2025, Resident #1 (R1) experienced an unwitnessed fall and activated their pendant. Staff #1 (S1) found R1 on the floor. 911 was called, but the R1 refused transport. R1’s emergency contact (EC) and primary care physician (PCP) were notified. On 12/14/2025, the Department received a subsequent incident report stating the R1 continued to report pain in their left ribs and shortness of breath. Staff #2 (S2) called 911, and R1 was transported to the hospital. The EC and PCP were notified. On 01/07/2026, the EC informed the facility that the R1 passed away on 01/06/2026 at approximately 1:00 p.m. at a Skilled Nursing Facility (SNF) upon discharge from the hospital. On 01/08/2026, CCLD received the death report, and LPA Mosley requested the death certificate from the facility. On 02/03/2026, LPA received the death certificate and LPA Esther Cortez contacted the facility telephonically to request R1’s care plan and physician report.

On 02/04/2026, LPA Mosley conducted the initial unannounced visit. During the visit LPA 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. CCLD’s Investigations Branch continued the investigation. The Department requested Ventura County Fire Department (VCFD) for the emergency medical service (EMS) report / medical records, 911 audio recording and call logs related to R1 on 12/11/2025 and 12/15/2025.