During the initial visit on 05/14/2025, between 9:30 a.m. and 1:30 p.m., LPA Conway briefly toured the facility, conducted interviews with the Executive Director (ED), Monica Reyes and one facility staff, and conducted a medication audit and obtained copies of pertinent documents relevant to the investigation.

On 05/21/2025 and 05/22/2025, LPA Dulek reviewed and obtained copies of facility video surveillance relevant to the investigation.

On 05/29/2025, LPAs Arroyo, Conway, Dulek, and LPM Heffernan conducted a plant tour starting at 11:05 a.m., conducted interviews with the ED, Monica Reyes and two staff members between 9:54 a.m. and 1:00 p.m., conducted a medication review starting at 1:00 p.m., and obtained copies of pertinent documents relevant to the investigation.

On 07/15/2025, approximately between 10:33 a.m. and 01:30 p.m., Investigator Padilla conducted interviews with the ED, Monica Reyes and two staff members: on 07/21/2025, at approximately 10:20 a.m. with R1’s family member and at approximately 11:00 a.m. with Investigator with the Medical Examiner’s Office; on 08/14/2025, at approximately 10:35 a.m. with the local Ombudsman; on 09/12/2025, at approximately 12:06 p.m., with a Sargeant from the Camarillo Police Department; on 09/18/2025, at approximately 10:35 a.m., with one staff member; and on 09/19/2025, approximately between 12:06 p.m. and 12:17 p.m., with two staff members. Investigator Padilla also requested and reviewed copies of Camarillo Police Department Report #25 – 57592, Emergency Medical Services (EMS) Report, County of Ventura Medical Examiner’s Office Autopsy / Coroner’s Report #0795 – 25, Ventura County Clerk’s and Recorder’s Office Death Certificate, and facility file documents related to the investigation.

Record review and interviews conducted revealed that R1 was admitted to the facility on 10/01/2024. A review of R1’s Physician’s Report, dated 04/22/2024, listed R1’s primary diagnosis as muscle weakness, hyperlipidemia, hypertension, edema, osteoporosis, glaucoma, and chronic kidney disease stage 3.

Report Continued on LIC 9099C...

The investigation revealed that on 05/11/2025, R1 was found unresponsive in their bedroom by facility staff. Staff then called 911 and began administering Cardio Pulmonary Resuscitation (CPR). Upon arrival, law enforcement personnel continued CPR until paramedics arrived on scene.

Staff interviews revealed that R1 maintained a consistent medication schedule. R1 received morning medication in the dining room at approximately 7:00 a.m., noon medication in their room, and evening medication in the dining room at approximately 4:00 p.m. Staff confirmed that R1 received their evening medication on May 10, 2025, during dinner time. Further staff interviews revealed that on that same day, R1 appeared “normal, as usual—nothing had changed,” with no observed changes in behavior or health status.

According to the Coroner’s Report, the cause of death was hypertensive heart disease, with contributing factors including chronic kidney disease and aortic valve disease. The manner of death was determined to be natural. The report also indicates that a toxicology examination was conducted on R1, which identified several medications listed in R1’s medication record, further confirming that R1 was receiving their prescribed medications while residing at the facility. Similarly, the death certificate listed the causes of death as acute myocardial infarction, coronary artery disease, hypertension, and hyperlipidemia. Furthermore, law enforcement found no evidence of foul play and closed their investigation.

Based on the information gathered during the course of the investigation, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, allegations “Due to staff neglect/lack of care and supervision resulting in a questionable death” and “Staff failed to assist R1 with the self-administration of medication which attributed to R1’s death” are deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was provided.

On 05/21/2025 and 05/22/2025, LPA Dulek reviewed and obtained copies of facility video surveillance relevant to the investigation.

On 05/29/2025, LPAs Arroyo, Conway, Dulek, and LPM Heffernan conducted a plant tour starting at 11:05 a.m., conducted interviews with the ED, Monica Reyes and two staff members between 9:54 a.m. and 1:00 p.m., conducted a medication review starting at 1:00 p.m., and obtained copies of pertinent documents relevant to the investigation.

It was alleged that staff did not respond to Resident #1 (R1) calls for assistance. It was reported that R1 repeatedly called the facility at approximately 3:00 a.m. the morning before their passing. A review of R1’s cell phone call log revealed that R1 attempted to contact the facility’s front desk numerous times during the early morning hours of 05/11/2025. According to the record, between 12:32 a.m. and 3:29 a.m. on 05/11/2025, R1 placed a total of thirty (30) calls to the facility. Staff interviews revealed that although a caregiver observed R1’s call light activated that night, they chose not to respond. Staff reported that R1’s call light was frequently activated and often ignored, as R1 was known to request assistance frequently throughout the day and night. Staff further stated that although certain residents require status checks every fifteen (15) minutes, not all staff consistently followed this guideline. Based on the information obtained and reviewed during the course of the investigation, the Department has sufficient evidence to support the allegation of “staff did not respond to R1’s call for assistance”. Therefore, this allegation is deemed Substantiated at this time.

Report Continued on LIC 9099C...

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies are cited (refer to LIC9099-D).

Additional violations will be cited at a later date. Exit interview conducted. A copy of the report and appeal rights were provided.