Inspector’s narrative
What the inspector wrote
Continued from LIC 9099-C
On 03/17/2025, from 12:28pm to 1:35pm, Licensing Program Analyst (LPA) Teresa Camara conducted an initial complaint investigation visit regarding the above noted allegation. LPA Camara met with Executive Director/Administrator Monica Reyes and explained the reason for the visit. Starting at 12:40pm, the LPA reviewed and obtained pertinent documents. At 1:11pm, the LPA conducted a health and safety check of the memory care (Meadows) side of the facility. The LPA determined further investigation was needed prior to issuing findings.
On 03/19/2025, from approximately 9:45am to 12:25pm, Investigator Santana conducted interviews with facility staff, Administrator, and attempted an interview with R1 (R1 unable to be interviewed due to condition of dementia); on 03/25/2025, from approximately 11:40am to 3:45pm, with R1’s resident representative, staff, Resident Care Coordinator, and attempted an interview with R2 (R2 unable to be interviewed due to condition of dementia); on 04/01/2025, at approximately 11:35am, with Ventura County Sheriff’s Office (VCSO) Detective; on 04/08/2025, from approximately 11:30am to 1:05pm, with facility executive director where R2 previously resided, Administrator, and R2’s resident representative; on 04/09/2025, at approximately 4:30pm, with staff; on 04/24/2025, at approximately 3:40pm, with VCSO Detective; on 05/07/2025, at approximately 3:50pm, with Tranquility Care Hospice case manager; on 05/08/2025, at approximately 4:05pm, with Tranquility Care Hospice CEO; on 05/12/2025, from approximately 11:55am to 1:25pm, with Tranquility Care Hospice LVN and CEO; on 05/15/2025, from approximately 1:50pm to 1:55pm, with VCSO Detective and R2’s Primary Care Physician (PCP), and on 05/23/2025, at approximately 11:25am, with R1’s resident representative. In addition, Investigator Santana reviewed facility surveillance footage, VCSO Report #25-31644, Body Worn Camera (BWC) footage, crime scene photos, 911 recording, Oxnard Police Department Report #2023-00014555, Tranquility Care Hospice records, Internal Medicine of Ventura medical records, Link Neuroscience Institute medical records, and resident and staff facility documents.
Continued on LIC 9099-C
Continued from LIC 9099-C
According to R1’s facility file review, R1’s physician report, dated 05/09/2024, listed mild cognitive impairment, R1 required the use of a wheelchair due to weakness, and needed assistance with all activities of daily living (ADLs) with the exception of eating. R1 was admitted to the facility on 05/16/2024. The physician report, dated 12/11/2024, listed R1 as having chronic congestive heart failure and dementia. R1 was admitted to hospice on 12/11/2024 with a primary diagnosis of Alzheimer’s disease after being discharged from a skilled nursing facility and being admitted to the facility’s memory care unit. R1’s Needs and Services Plan was incomplete and did not list any needs or services for R1. The facility logs review revealed that R1 was on 15-minute checks, and incontinence checks every two hours.
According to R2’s facility file review, R2’s physician report, dated 01/08/2025, listed the primary diagnosis as dementia and noted wandering behavior. R2 was admitted to the facility on 02/03/2025. R2’s Needs and Services Plan was incomplete and did not list any needs or services for R2. The facility logs review revealed that R2 was on 15-minute checks, and incontinence checks every two hours.
A review of the Oxnard Police Department Case Report 2023-00014555 revealed that on 02/28/2023, R2 was arrested and charged with domestic violence.
Information obtained from the Link Neuroscience Institute medical records revealed that on 12/26/2023, after performing testing, the neuropsychologist assessed that R2’s mental status and gross cognitive functioning were significantly reduced. After reviewing the remaining tests, the Dr. concluded that R2 fulfilled a diagnostic criterion for a major neurocognitive disorder, with the most likely explanation being probable Alzheimer’s disease.
Continued on LIC 9099-C
Continued form LIC 9099-C
The Internal Medicine of Ventura medical records revealed that on 03/04/2025, R2’s Primary Care Physician (PCP) was informed that R2 was fearful, anxious, and aggressive when trying to defend self and “girlfriend” at the facility due to delusions of persecution. The PCP was informed that R2 pushed a caregiver aggressively and caused injury. In response, the PCP increased the Seroquel dosage. R2 stated they did not like the rules of the memory care unit, admitted to feeling frightened and said they would be willing to fight. R2’s resident representative reported that Seroquel was not being given by the facility because R2 was refusing it.
Further information obtained through interviews revealed R2 was noted to be agitated and aggressive with caregivers at previous facilities R2 resided in. According to the Administrator, R2 was evicted from their previous facility due to aggression.
According to the Unusual Incident/Injury Report (UIR) submitted by the facility, on 03/14/2025 at 8:50pm, Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3) were in memory care’s common area preparing to start their next diaper changes when they noticed someone opening and closing R1’s door. S2 tried opening the door, but R2 kept pushing the door closed. When staff made their way inside, R2 left the room. R1 alleged that “the man” tried touching her private part. When asked for details, R1 said the man touched her legs and her “hole”. Staff called the Resident Care Supervisor, who in turn called 911. The report states that R1’s hospice agency was notified so a nurse could assess R1, but R1 said she was not hurt or in any pain. (The Department’s investigation revealed that the facility did not contact the hospice agency. The hospice agency was made aware of the incident from R1’s resident representative on 03/16/2025.)
Continued on LIC 9099-C
Continued from LIC 9099-C
A review of the facility surveillance footage showed that on 03/14/2025, at around 8:31pm, the lead staff used their key to access R1’s room. When the lead staff emerged about a minute later, they pulled the door closed. At 8:48pm, S1, S2, and S3 were all in the common area, R2 sat in the same area. R2 stood up and left he common area at 8:50pm, making their way down the hallway, as the three staff remained in the common area. As R2 walked down the hallway, R2 turned the knob of one door and continued walking after realizing the door was locked. Then at around 8:51pm, as R2 turned the knob to R1’s door, R2 realized the door opened, so R2 walked inside. At about 8:57pm, the staff ran down the hallway and went inside R1’s room. Seconds later, R2 emerged and continued walking down the hallway, checking every doorknob as R2 walked by.
Based on the review of the Ventura County Sheriff’s Office (VCSO) Report #25-31644, the VCSO investigation found probable cause that R2 pulled R1’s diaper down and digitally penetrated R1’s anus without consent. The evidence consisted of R1 telling deputies that a man entered R1’s room and inserted his finger in R1’s anus; and the facility staff statements that R2 was in R1’s room and that R1’s diaper had been pulled down. Due to R2’s mental capacity, R2 was not arrested. Although the facility’s practice is to lock all memory care residents’ rooms to prevent other residents from entering, it is evident that R1’s door was not adequately secured the last time a facility staff member entered R1’s room on 3/14/2025 at 8:30pm before R2 did at 8:50pm. R1 was to be checked every 15-minutes and was due to be checked at 8:45pm, but the video footage and the “15-minute checks” log show no one checked on R1 at that time. Had a staff completed that check, there is a possibility that R1’s door would have been correctly secured afterward. Additionally, when R2 left the common area and walked down the hallway, none of the three staff monitored R2’s activities despite all standing in the common area and knowing R2’s history of wandering and attempting to access other residents’ rooms. As a result, R2 accessed R1’s room and remained there for six minutes before being discovered by staff.
Continued on LIC 9099-C
Continued from LIC 9099-C
Facility interviews revealed that R2 had at least two prior nonconsensual intimate interactions with two other residents, but such behaviors were not reported to R2’s Primary Care Physician (PCP). The PCP stated that had they been notified they would have requested for R2 to be seen for an assessment. Therefore, the allegation that R2 sexually assaulted R1 as a result of facility neglect is Substantiated at this time.
A $1000 immediate civil penalty is assessed today for repeat violation of 1569.312(a) Basic Services as licensee was previously cited on 10/14/2024. The
Executive Director/Administrator, Monica Reyes,
was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f).
Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC9099-D).
Exit interview conducted, appeal rights discussed, and a copy of this report issued.
