565800366-5-22-2025-29-AS-KDUK-DGWQEG-20250522120619

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800366
Report Date: 05/22/2025
Date Signed: 05/22/2025 12:06:39 PM

Document Has Been Signed on 05/22/2025 12:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 125	DATE:	05/22/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:28 AM
MET WITH:	Remon Pagels		TIME VISIT/ INSPECTION COMPLETED:	12:10 PM

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Licensing Program Analyst (LPA) Kelly Dulek conducted a case management visit with the purpose of continuing the investigation into a self-reported incident/death report. LPA arrived at the facility at 09:28AM and was greeted by front desk staff. LPA met with Executive Director (ED) Remon Pagels shortly after the visit began. Entrance interview conducted.

An incident report and separate death report were received at the Woodland Hills Regional Office on 12/16/2024. Incident report indicated that on 12/15/2024, resident’s family member called the front desk asking for staff to check on Resident #1 (R1). Caregiver went to check on R1 and found R1 “passed away by taking [R1's] own life.” Caregiver called med techs, 9-1-1 was called and ED was contacted. LPA called ED and requested relevant facility documents for R1, including care plan and physician’s report. LPA requested the related police report from Ventura County Sheriff’s Office (VCSO.) LPA received the facility documents on 12/17/2024. The death investigation was referred to Community Care Licensing Division (CCLD)’s Investigation Branch (IB) and was assigned to Investigator Dennis Douglas. Investigator Douglas obtained relevant medical records for R1 and conducted both in person and telephonic interviews with staff, residents, and other relevant parties on the following dates: 01/03/2025, 02/07/2025, 02/18/2025, and 02/19/2025. LPA Dulek then reviewed all documents provided by the facility and IB Investigator. The following was then determined:

Record review revealed that R1 had lived in the facility since 07/28/2018. According to facility staff, R1 served as a “facility ambassador” and was typically very social amongst the facility residents and potential new residents. R1 was described by ED as “independent;” incident report indicates R1 was not on care plan, medication management, or status check. Physician’s report signed on 06/14/2019 indicates R1 was able to Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Kelly Dulek
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ATRIA HILLCREST	FACILITY NUMBER: 565800366
	VISIT DATE: 05/22/2025

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store and administer their own prescription and PRN medications and able to care for their own activities of daily living (ADLs.) Diagnoses listed as of 06/14/2019 include but are not limited to: anxiety disorder due to another medical condition and major depressive disorder, recurrent episode. Atria’s Resident Functional Needs Service Plan dated 10/21/2024 also lists these diagnoses and indicates R1 able to self-manage medications and does not require assistance with ADL care. However, on 12/02/2024, R1 was treated for a urinary tract infection (UTI) and was given antibiotics, a catheter, Buspar and Zoloft because R1 was anxious about urinating. R1 returned to the facility. After returning to the facility, staff noted R1 to be staying in their room more often and ordering tray service rather than eating meals in the common dining room. Documents reviewed revealed that Atria staff knew R1 was “having medical issues and depression because of these medical issues.” Staff knew that for about 2-3 weeks R1 did not leave their room for meals and for 2-3 days prior to R1’s death that R1 refused to eat some of their meals. Interview with R1’s family member revealed that R1 was reacting to the medication prescribed and R1 was experiencing increased anxiety. R1’s physician discontinued use of this particular medication on 12/09/2024. Physician explained to R1 and their family member that R1 would continue to experience the effects (bouts of depression) as the medication cycled out of R1’s system over several days. R1’s family member stated they did not directly inform the facility staff of the change in medication, the effect the medication had on R1 nor that R1 expressed suicidal ideations. On 12/15/2024, R1’s family member was unable to reach R1 by telephone and requested the facility staff conduct a status check. Staff found R1 in their room, apparently deceased and called 9-1-1. Responding police deemed R1’s death a suicide and R1’s death certificate indicated manner of death was suicide, cause of death listed as smothering asphyxia. Staff and ED interview revealed that R1 was “independent” and R1’s care plan dated 10/21/2024 does not indicate R1 required status checks, so facility staff stated they did not conduct regular status checks on R1. Executive Director provided LPA with documentation indicating a care task was added on 12/09/2024 directing care staff to “monitor for signs of anxiety” 7 days a week at 08:00AM, 01:00PM and 06:00PM through 12/23/2024. However, the facility did not provide documentation of status checks being completed and staff working on the date of R1’s death stated they checked on R1 due to the call from R1's family member and/or due to R1 not arriving in the dining room for breakfast. Staff did not mention status checks as a regularly scheduled task for R1. Additionally, no reassessment was completed following R1’s change in condition (UTI diagnosis and insertion of an indwelling catheter and increasing anxiety/depression.) And although R1 had previously been socially engaged at the facility, when staff noticed R1 was not leaving their room, no new care plan was initiated for R1.

Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Kelly Dulek
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

LIC809 (FAS) - (06/04)

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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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ATRIA HILLCREST	FACILITY NUMBER: 565800366
	VISIT DATE: 05/22/2025

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Additionally, R1’s physician’s report signed on 06/14/2019 indicates R1 was able to store and administer their own medications, so leading up to R1’s death, facility staff was not assisting R1 with medications. However, no new physician’s report was completed due to R1’s change in condition. R1’s family member stated they did not directly inform the facility staff of R1’s change in medications. It should be noted that Atria policy on file with the Department states that all residents, including those who store and manage their own medications, are required to keep a current medication list on file with the facility. ED stated that this policy is no longer in effect, however Atria did not inform the Department of the change in policy. The medication list on file for R1 was dated 07/05/2018, therefore was not updated with the medications prescribed for the UTI on 12/02/2024. Even though the facility did not complete a reassessment nor obtain a new physician’s report or medication list following a change in condition, it is unclear whether these were contributory factors in R1’s suicide. The investigation did not provide sufficient evidence to prove a lack of care and/or supervision led to R1’s death.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency is cited (refer to LIC809-D). ED was informed that failure to correct the deficiency may result in civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Kelly Dulek
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/22/2025 12:06 PM - It Cannot Be Edited

Created By: Kelly Dulek On 05/22/2025 at 10:42 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: ATRIA HILLCREST	FACILITY NUMBER: 565800366
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/22/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/06/2025 Section Cited CCR 87463(a)	1 2 3 4 5 6 7	87463 Reappraisals (a) The pre-admission appraisal...shall be updated in writing as frequently as necessary...to note significant changes in condition...and to keep the appraisal accurate...updated pre-admission appraisal shall be referred to as reappraisal This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Executive Director indicated the facility has already begun using a document to be used upon hospital discharge to indicate whether the resident has had a change in condition. Inservice training was conducted on resident change in condition. POC cleared.
	8 9 10 11 12 13 14	Based on interview and record review, R1 had a change of condition on or around 12/02/2024 (hospitalization, UTI, catheter, medication change and increased anxiety/depression) however, the facility did not conduct a reappraisal, which posed a potential health risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:

	Kelly Dulek
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

LIC809 (FAS) - (06/04)

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