565800366-7-25-2025-29-AS-EMOY-DJWNHH-20250725102847

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800366
Report Date: 07/25/2025
Date Signed: 07/25/2025 10:29:04 AM

Document Has Been Signed on 07/25/2025 10:29 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ATRIA HILLCREST		FACILITY NUMBER:	565800366
ADMINISTRATOR/ DIRECTOR:	REMON PAGELS		FACILITY TYPE:	740
ADDRESS:	405 HODENCAMP RD		TELEPHONE:	(805) 373-0606
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY: 207		CENSUS: 131	DATE:	07/25/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:55 AM
MET WITH:	Remon Pagels- Executive Director		TIME VISIT/ INSPECTION COMPLETED:	10:35 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	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

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ATRIA HILLCREST	FACILITY NUMBER: 565800366
	VISIT DATE: 07/25/2025

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(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.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025

LIC809 (FAS) - (06/04)

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