Incident investigation·July 25, 2025

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. Report continued on LIC 809-C PAGE 2 (PAGE 2) Report continued from LIC 809 Record review revealed that R1 had lived at the facility since 10/31/2024. R1 was on level 0 of level of care, indicating that at the time of move in R1’s comprehensive assessment indicated that R1 did not require personal care services offered by the facility. R1 was able to leave the facility unassisted. R1 did not have a history of suicide attempts/suicidal ideation. Interviews with the ED revealed that R1 was fully independent, still drove their personal vehicle, and had no changes in condition or care other than some recent falls. R1 would often sign themselves out and leave the community in their personal vehicle. The facility strictly prohibits firearms and there was no indication that R1 possessed a firearm. The resident had not exhibited signs of unhappiness or distress. When the ED spoke to R1 on 05/09/25 and 05/10/25 they appeared to be their usual self. R1 maintained a wide network of outside friends and was known to be friendly and communicative with staff. Interviews with staff revealed that R1 was highly independent and rarely needed help from staff. Staff were familiar with R1 but had limited direct interaction with R1 due to their high level of independence. Police report indicated that there was no evidence of foul play or suspicious activity, and the cause of death was suicide. No deficiencies are being cited at this time pertaining to this self-reported incident and death report. Exit interview conducted and a copy of report was provided.