Incident investigation·November 4, 2025

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced Case Management - Incident visit at 10:40AM. The purpose of this visit is to conduct an investigation regarding a self-reported incident that occurred on 08/15/2025. LPA met with Executive Director (ED) Zachary "Zak" Howel and explained the reason for the visit. During today’s visit, LPA conducted a brief physical plant tour to ensure there are no immediate health and safety hazards and conducted interviews with two (2) staff members. During LPA’s initial visit on 10/06/2025 regarding this incident, LPA interviewed five (5) staff and one (1) resident, reviewed and obtained copies of pertinent documents relevant to the investigation, and conducted a brief physical plant tour. On 08/19/2025, the Department received an incident report and SOC341 stating that on 08/15/2025, Staff #1 (S1) was observed telling Resident #1 (R1) to “shut up.” S1 was immediately placed on administrative leave pending the facility’s internal investigation and was subsequently terminated on 08/22/2025. R1 was assessed for injuries immediately after the incident was reported and no injuries or marks were observed on R1. R1’s responsible party, the Department, the Long-Term Care Ombudsman, and local law enforcement were notified. Ventura County Sheriff conducted a visit regarding the incident on 08/19/2025. Elder abuse and reporting standards training was proactively conducted with staff on 08/19/2025. LPA interviewed R1 on 10/06/2025 and no concerns were noted. LPA discussed mandated reporter requirements with staff and reviewed their signed and dated SOC341A acknowledgments. An additional report may follow if warranted. Exit interview conducted. A copy of the report was provided.