Complaint Investigation Report

as well as toured the facility and obtained copies of additional documents. On 11/14/2024, LPA, along with Long Term Care Ombudsman (LTCO) MaeRetha Coleman conducted a subsequent complaint investigation. During the visit, LPA and LTCO interviewed Administrator at 09:45AM and conducted a health and safety check tour of the facility at 10:38AM. Administrator was informed throughout the visits that the complaint was referred to Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Phillipe Ryan Miles for investigation. Investigator Miles obtained and reviewed copies of Ventura County Sheriff’s Office (VCSO) reports related to the incident. Investigator Miles also interviewed Administrator on 03/06/2025. Throughout the course of the investigation, LPA Dulek reviewed all documents and reports obtained. During today’s visit, LPA reviewed and obtained a copy of the Medication Administration Record (MAR) for Resident #1 (R1). The following was then determined:

Allegation: “Neglect/lack of care & supervision – Resident 1 (R1) caused severe injuries to Resident 2 (R2) that led to the death of R2:”

The complaint alleges that an incident occurred on the morning of 11/01/2024, which resulted in R2’s death. LPA Dulek received a telephone call on 11/01/2024. Administrator indicated to LPA that an incident had occurred between two (2) residents at the facility, which resulted in R2 passing away due to the injuries sustained. LPA conducted a case management visit on 11/01/2024; a written incident report was provided to the LPA during the visit. VCSO interviewed all staff working at the facility on the overnight shift when the incident occurred. Review of interviews revealed that during the overnight shift that took place from 10:00PM on 10/31/2024 to 06:30AM on 11/01/2024, Resident #1 (R1) was observed to be agitated. Initially, the facility charge nurse radioed for assistance in the shared room belonging to R1 and Resident #2 (R2) before midnight. Staff #1 (S1) and Staff #2 (S2), who were working as caregivers during the overnight shift responded to the call for assistance. R2 was non-ambulatory and required assistance with activities of daily living (ADLs) such as toileting and transfer assistance. R2 was attempting to get out of their bed at that time. S1 and S2 provided care to R2 and observed that R1 was awake and concerned with the commotion in their shared room. Staff reassured R1 that everything was okay before leaving the room. Around 03:30AM, staff saw R1 walking around the common areas. R1 had a staff radio in their hand, as well as the foot rest from a wheelchair. S1 and S2 attempted to calm R1 as R1 indicated they were hearing voices and seeing “somebody.” Staff indicated R1 was “inconsolable and agitated.” All 3 (three) staff working the overnight shift observed R1’s behaviors around 03:30AM. While two (2) Silverado staff walked away, leaving R1 in the common area, S1 agreed to walk R1 to their room and check the room for R1’s safety. R1 began swinging the wheelchair leg at S1, resulting in a scratch to S1’s left forearm. S1 was able to take the items from R1