On 10/2/25, at 01:00pm Licensing Program Analyst (LPA) Nancy O’Connell conducted a Case Management - Incident inspection follow-up and to deliver investigation findings at the above-listed facility, and met with Kimberly Bennet Facility Administrator (FA) and Theresa Plante, Regional Director (RD), in response to a Special Incident Report that was received by Community Care Licensing (CCL) on 9/22/25 . The incident, which occurred on 9/19/25, involved client (C1), who incurred a serious injury while in the care of the facility, resulting in death.

On 9/22/25, a Special Incident Report (SIR) was received by Community Care Licensing Division (CCLD), reporting a serious injury to a client in care. The SIR reported that on 9/19/25, a client (C1), incurred a serious injury when she exited the facility property and entered a nearby public highway, where she was struck by a vehicle. The report indicates that staff were immediately present prior to the incident as well as during the incident to provide supportive interventions, including road management assistance, contact with emergency personnel, and alerting additional facility staff for support. The youth, C1, was transported by emergency responders to a local hospital where she was initially treated for injuries. On 9/24/25, LPA O’Connell received information from the assigned County Social Worker, Jenna Santos, that youth C1 passed away on 9/23/25, from injuries incurred during the incident.

During the time of the inspection, LPA O’Connell interviewed C5 and C2 to obtain information related to the events leading up to the special incident event that occurred on 9/19/25.

Throughout the course of this investigation, LPA O’Connell interviewed facility staff, child welfare representatives, and additional witnesses. LPA O’Connell conducted a physical inspection of the facility property to confirm the physical course of action taken by C1 on the night of incident. LPA O’Connell confirmed access points/exits for the facility and staff verified secure doors as well as a single open access door. LPA O’Connell reviewed all available documentation related to the incident including treatment records for C1, staff training records, facility policies, visual footage taken from facility cameras, and a Ventura County Emergency response call-log. A request was made to the Ventura County Sheriff’s Department to provide a law enforcement report if/when one becomes available.

Based on the evidence gathered, facility staff utilized established Emergency Interventions procedures consistent with their established Elopement Policy within their Program Statement. Once it was determined that C1 was escalating and attempting to leave the facility premises, staff followed and maintained a visual of C1, while attempting to redirect her back to the facility. Staff reports and visual evidence are consistent with staff maintaining supervision of youth, C1. Further, emergency intervention policies reviewed indicate that a physical restraint by staff was not indicated due to lack of verbalized threat to self by C1. Lastly, emergency call logs obtained reflect an immediate call to support staff and emergency responders once it was determined that the youth needed immediate medical assistance.

There is no evidence to prove that a violation has occurred. There are no deficiencies cited at this time. This investigation has been closed.

Exit Interview conducted, and a copy of this report was sent to the Facility Administrator (FA).

• 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.