405800577-5-27-2026-29-AS-KBUY-DUJS73-20260529133653

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405800577
Report Date: 05/27/2026
Date Signed: 05/27/2026 05:28:07 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/04/2026 and conducted by Evaluator Garrett Haner-Tomasko

COMPLAINT CONTROL NUMBER: 29-AS-20260504152017

FACILITY NAME:	VILLAGE AT SYDNEY CREEK, THE		FACILITY NUMBER:	405800577
ADMINISTRATOR:	AUDIE SHERBERG		FACILITY TYPE:	740
ADDRESS:	1234 LAUREL LANE		TELEPHONE:	(805) 543-2350
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	84	CENSUS: 48	DATE:	05/27/2026
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator - Audie Sherberg		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Resident ingested a hazardous substance while in care due to staff neglect.

INVESTIGATION FINDINGS:

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At 9:30am, on 5/27/2026, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to further investigate the allegation of this complaint and deliver final findings. LPA met with Administrator Audie Sherberg, announced who he was and the reason for the visit.

During a visit conducted on 5/6/2026 LPA conducted interviews, collected relevant documentation and toured the interior and exterior of the facility.

On the allegation, resident ingested a hazardous substance while in care due to staff neglect; it was alleged that Resident #1 (R1) ingested rat poison while in care at the facility.

(Continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026

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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20260504152017

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: VILLAGE AT SYDNEY CREEK, THE	FACILITY NUMBER: 405800577
	VISIT DATE: 05/27/2026

NARRATIVE

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An incident report submitted by the facility to Community Care Licensing (CCL) on 5/4/2026 states that on 5/3/2026 at approximately 6:00pm staff observed R1 walking in the garden area with a rodent bait station in hand. The bait station was open and contained rodent control bait pellet packets. R1 had removed the packets and they appeared torn and wet. Staff washed R1’s hands, Poison Control was contacted by staff, and they advised staff to send R1 to the hospital for evaluation. The pellet packaging indicated the pellets were bromethalin. R1 was observed at the hospital, treated for possible ingestion of bromethalin, and returned to the facility the next morning. The report also states that on 5/4/2026 the Administrator had the maintenance department remove all remaining bait stations in the courtyards accessible to residents and that the pest control company would visit the community to inventory and double check that all bait stations were removed.

Staff interviews confirmed the events that happened on 5/3/2026 according to the incident report and they are not sure if R1 ingested the bromethalin but did notice at least one of the packets appeared torn open, not like a rodent would chew it open but torn open, and the packet appeared wet at the tear. Staff stated emergency responders took the packets with them. Interviews and hospital discharge documents stated that there is no widely available test to determine if there is bromethalin in a human’s system and it was not determined if R1 had ingested bromethalin. Hospital discharge documents also state R1 was treated with oral medication as a precaution. Additionally, staff stated that when they notified the Administrator about the incident they were instructed to activate the approved egress devices on all doors leading to the courtyards to keep residents from accessing any additional bait stations in the courtyard without staff being alerted. Staff state that the egress devices are usually deactivated to allow residents to wander the courtyard freely since there are additional egress devices on the perimeter gate of the courtyard, and staff are expected to conduct regular checks every 30 minutes on the residents in the courtyard. R1 was found during one of the 30-minute checks, but staff state that the checks sometimes are not conducted on time with up to an hour passing between checks.

Interviews revealed that R1 enjoys gardening and spends a lot of time in the facility courtyard; it can be difficult to redirect R1 from the gardening tasks they are doing in the courtyard; and R1 sometimes gets frustrated when they do try. Staff stated in the past R1 has removed the in-ground utility box covers in the courtyard that give access to electronic irrigation valves.

(Continued on LIC9099-C)

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20260504152017

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: VILLAGE AT SYDNEY CREEK, THE	FACILITY NUMBER: 405800577
	VISIT DATE: 05/27/2026

NARRATIVE

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Interviews also revealed that three days prior to the incident on 5/3/2026, on 4/30/2026, R1 was found by staff sitting on a bench in the courtyard with an open faux rock bait station and approximately ten packets of bait laid neatly out on a rag on the bench next to R1. These packets did not appear to be open. Staff brought R1 into the dining/living room area of neighborhood two and notified a medication technician (med-tech). The med-tech observed R1 and had R1 wash their hands. The med-tech told staff to monitor R1 for any changes in condition, they removed the pellet packets from the station and disposed of them. The med-tech instructed the staff to return the empty bait station back to it’s place in the courtyard and as the staff was headed outside the facility nurse came into the dining/living room area. It was communicated to the nurse that R1 had the bait station but no one ever mentioned to the nurse that R1 had opened the station and had access to the bromethalin pellet packets. Interviews also revealed that this incident on 4/30/2026 was not communicated to the Administrator until the incident on 5/3/2026.

Review of R1’s medical assessment (LIC602A) dated 7/29/2025 states the safety of R1 and other residents is at risk if R1 is given access to personal care and hygiene items, but R1 and other residents are not at risk if R1 is given access to poisonous substances. R1 opening the bait stations posed a risk to not only themselves but also other residents. R1’s preadmission appraisal dated 8/23/2025 and service plan dated 9/9/2025 do not mention any risks or non-risks to R1 regarding poisonous substances.

The Administrator stated that they were hired in June of 2025 and approximately seven months prior to the incident on 5/3/2026, they became aware of rodent bait boxes throughout the outside of the facility including in the courtyards accessible to residents through each neighborhood. At that time they were black boxes without a key lock that the Administrator felt were easy to break open, they had the pest control company switch the black boxes out for the bait stations that R1 had during both incidents. These rodent bait stations are shaped to look like a light grey rock and are opened with a key mechanism. The exterior of the faux rock bait stations state “Caution! Bromethalin 0.01%.” The Administrator states the pest control company says these stations are child and pet resistant. It is still undetermined how R1 opened the locked bait station.

A pest control service invoice dated 5/4/2026 states eight external bait stations (EBSs) were collected from the facility that had been in the neighborhood courtyards and four remain on the front of the property. The front of the property is inaccessible to residents in the neighborhoods.

(Continued on LIC9099-C)

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20260504152017

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: VILLAGE AT SYDNEY CREEK, THE	FACILITY NUMBER: 405800577
	VISIT DATE: 05/27/2026

NARRATIVE

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Based on all interviews conducted and documents obtained, the allegation above could not be proven, that the resident ingested the hazardous substance. Therefore, at this time the allegation was found to be unsubstantiated, meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

During today’s visit LPA conducted a case management visit addressing a continued concern of hazardous/poisonous substances accessible to residents in care and addressing the need for staff to better communicate during incidents like the one that occurred on 4/30/2026. Technical Assistance is also issued for Observation of the Resident.

Exit interview conducted, report signed, and report provided to the Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026

LIC9099 (FAS) - (06/04)

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