Incident investigation·May 6, 2025

Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent case management visit to deliver findings for the death investigation initiated on 02/27/2024 case management visit. LPA met with Administrator Cilva Toume and Assistant Administrator Vana Barberis and explained the reason for the visit. On 02/26/2024, the Department received a self-reported death report from the facility. The death report stated that on 02/20/2024, Resident #1 (R1) was seen choking on their saliva by the caregiver on duty. The caregiver immediately called 911 and began CPR. The Department referred the case to the Community Care Licensing (CCL) Investigations Branch (IB). The case was assigned to Investigator Laura Garcia to conduct the investigation. On 02/27/2024, from 3:15pm to 6:45pm, Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management – Incident visit to the above facility. LPA Cortez met with the administrator Cilva Toume and explained the reason for the visit was to follow up on the self-reported death report received on 02/26/2024. The report pertained to the 02/20/2024 death of Resident #1 (R1). During the visit, the LPA conducted interviews with staff and R1's resident representative, conducted a brief tour of the facility, and obtained copies of pertinent documents. The LPA informed the administrator that the incident was referred to the Community Care Licensing (CCL) Investigations Branch (IB) for review and further investigation was required prior to issuing findings. Report will continue on LIC809-C, 2nd page. On 03/04/2024, at approximately 12:00pm, CCL IB Investigator Garcia conducted an interview with the administrator; on 03/07/2024, from approximately 11:45am to 2:30pm, with administrator, staff, and resident; on 04/15/2024, at approximately 12:00pm, with R & G Home Health Care Services medical staff; and on 04/25/2024, at approximately 11:35am, with R1’s physician Dr. Gehlani. In addition, Investigator Garcia requested Ventura County Sheriff’s Department and Emergency Medical Services reports. To date, no reports have been obtained. A review of R1’s facility file documents indicate that R1 was admitted to the facility on 08/12/2022. R1’s Physician Report, dated 08/24/2023, lists diagnosis as HTN, HLD, and Hypothyroid. The report also lists Mild Cognitive Impairment (MCI), needs assistance with self-care, except for feeding, disoriented, confused, able to follow instructions and able to communicate needs. The investigation revealed that on 02/13/2024, R1 tested positive for COVID-19. Due to the diagnosis with COVID-19, R1’s physician, prescribed a nebulizer which consisted of 15-to-20-minute treatments. R & G Home Health Services conducted training with staff and R1 and visited R1 three times per week. It was noted in the home health notes that R1 was able to remove the nebulizer mask by their self. On 02/20/2024, at approximately 5:30pm, facility staff indicated that while R1 was receiving the nebulizer treatment, they were in direct line of sight of R1 and as soon as they noticed R1 was having trouble breathing, they immediately dialed 911 and performed CPR until paramedics arrived on scene. The paramedics arrived and continued with CPR measures. Per the administrator, the paramedics continued CPR measures for an additional 40 minutes until R1’s passing. R1’s certificate of death from Ventura County Registrar and Recorder office noted R1’s primary cause of death, was due to cardiac arrest and hypertension. COVID-19 was also noted as a significant contributing factor to R1’s death. During the course of the investigation, interviews were conducted with facility staff members, residents, R1’s physician Dr. Ghelani, and R & G Home Health Care Services medical staff. The home health clinical notes were also obtained and reviewed. R1’s physician and home health nurses denied observing neglect or lack of care by facility staff members. The home health agency was involved with the continuous care of R1. Report will continue on LIC809-C,3rd page. Staff described R1 as able to express their needs, despite age-related cognitive decline. R1 had the capability of self-administering the nebulizer treatment and training had been previously provided to staff on how to assist with R1's treatment and condition. Dr. Ghelani and the home health staff confirmed that R1 did not require direct supervision or one-to-one care during treatments. R1 had last been seen by the home health nurse on 02/19/2024 and there were no signs of respiratory distress noted. Based on the information obtained, there is insufficient evidence to support neglect/ lack of care leading to the death of R1. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview, copy of report given .