Incident investigation·November 20, 2025

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent case management visit to deliver findings for the above allegation. LPA met with Executive Director Joey Alvarado and explained the reason for the visit. On 02/11/2025, the Woodland Hills North Adult and Senior Care Regional Office (RO) received a report of the death of Resident #1 (R1). The report noted on 02/01/2025, R1 sustained a fall in their room. R1 was transferred to Los Robles Regional Medical Center Emergency Room (ER) and returned to the facility on 02/02/2025. On 02/04/2025, R1 reported not feeling well and was transported to the hospital and re-admitted. On 02/06/2025, it was reported that R1 passed away due to a brain bleed. On 02/11/2025, the RO referred this case to the Community Care Licensing (CCL) Investigations Branch (IB) Investigations Branch to investigate the allegation of Questionable Death. The case was assigned to Investigator Johnny Canto to conduct the investigation. On 02/11/2025, from 10:15am to 12:45pm, Licensing Program Analyst (LPA) Zabel Chochian conducted a Case Management – Incident visit. Upon arrival LPA Chochian met with the Administrator/Executive Director Johnny Ortiz and explained the reason for the visit. The reason for the visit was to follow up on a self-reported incident report. The report pertained to an incident involving Resident #1 (R1) who sustained an unwitnessed fall on 02/01/2025 at the facility and subsequently passed away on 02/06/2025 at Los Robles Regional Medical Center. (Continue to LIC809c) Due to the circumstances surrounding the death of R1, the LPA informed the Administrator/Executive Director that the incident was referred to the Community Care Licensing (CCL) Investigations Branch (IB) for further review. On 03/03/2025, from approximately 11:45am to 3:55pm, Investigator Canto conducted interviews with the Administrator/Executive Director, facility staff, and Resident #2 (R2). In addition, Investigator Canto reviewed Los Robles Regional Medical Center records, Ventura County Clerk Records Office Death Certificate, and facility file documents related to the investigation. A review of R1’s Physician Report, dated 09/23/2024, listed R1 as ambulatory; able to leave the facility unassisted; able to independently transfer to and from bed; able to store and administer their own medication; able to administer their own oxygen; able to perform their own glucose testing; and able to care for all of their activities of daily living (ADLs). R1’s Health and Services Evaluation, dated 09/18/2024, indicated R1 was non-ambulatory, listed the mobility/ambulation level of assistance as independent (“resident does not require assistance with mobility/ambulation”); has occasional left knee discomfort when ambulating, relieved by lidocaine patch; does not require supplemental oxygen, has an oxygen concentrator but does not use. The MFS (Morse Fall Scale) evaluation determined R1 was a high fall risk due to a history of falling, uses an ambulatory aid (walker/cane), and has a weak gait. The evaluation indicated to “implement high risk fall risk reduction interventions”. R1 did not require assistance with ADLs, except for help with putting on socks and shoes, and bathing may require reminding or standby assistance. R1’s Service Plan, dated 10/06/2024, lists diagnosis as diabetes, type II; gastroesophageal reflux disease (GERD); heart disease; atrial fibrillation; congestive artery disease (CAD); congestive heart failure (CHF); spinal stenosis; coronary artery disease; and chronic kidney disease stage 3. The Service Plan includes the same information found in the Health and Services Evaluation. (Continue to LIC 809c) Additionally, the plan documents the potential for high fall risk and indicates “R1 is a high fall risk, encourage to always ambulate with cane or walker, keep room free of clutter, encourage to wear proper shoes”. Medical records reviewed document that on 02/04/2024, R1 was admitted to the Los Robles Regional Medical Center with a chief complaint of respiratory failure. On 02/05/2025, R1’s diagnosis included increasing lethargic and shortness of breath. Further tests and x-rays were completed which indicated “the patient most likely has acute respiratory distress ad hypoxia secondary to COPD exacerbation secondary to pneumonia versus CHF exacerbation as well as AKI and hypoglycemia”. In addition, the records indicated a subdural hemorrhage. R1 was placed on comfort care and passed away on 02/06/2025. The Department’s investigation revealed on 10/05/2024, R1 was admitted to the Laurel Heights facility. R1’s physician report noted that R1 was independent and not a fall risk. However, the Facility Health and Services Evaluation and Service Plan both noted R1 was a high fall risk, was non-ambulatory, used a cane and/or walker, and was independent with mobility and ambulation. Staff interviews revealed R1 had no history of falls while residing at the facility, was independent, and only needed standby assistance for showering. On 02/01/2025, R1 sustained an unwitnessed fall in R1’s apartment. R1 was discovered on the floor by facility staff when doing rounds. R1 verbalized that they had fallen in their bedroom. Facility staff noted several lacerations to the back of R1’s head. 911 was called, paramedics arrived, and R1 was transported to the Los Robles Regional Medical Center via ambulance. R1 was medically treated and then discharged back to the facility on 02/03/2025. On 02/04/2025, the facility staff noted that R1 appeared lethargic and unable to answer simple questions. The facility staff called 911 again, paramedics arrived, and transported R1 to the hospital. On 02/06/2025, the facility received notification that R1 expired while at Los Robles Regional Medical Center due to a brain bleed. The cause of death was noted as blunt force head injury with subdural hematoma. The Department’s investigation found insufficient evidence to support the facility neglected the care and or safety of R1. Therefore, no citations are being issued at this time. Exit interview, copy of report given.