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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850072
Report Date: 05/05/2021
Date Signed: 05/05/2021 12:04:01 PM

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:SILVERADO THOUSAND OAKS, LLCFACILITY NUMBER:
565850072
ADMINISTRATOR:WILKIN, RONDAFACILITY TYPE:
740
ADDRESS:980 WARWICK AVETELEPHONE:
(805) 307-7300
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:82CENSUS: 17DATE:
05/05/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Ronda WilkinTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Ashley Smith and Sandra Urena conducted an unannounced Case Management - Incident visit at the facility today to follow up on an incident pertaining to Resident #1 (R1). The LPA met with Executive Director Ronda Wilkin and explained the reason for the visit. On 4/26/2021, the LPA received a call from the Executive Director, whom reported an elopement. On 4/25/2021 at approximately 7:47 p.m., R1 exited from the rear of the community though a service door. R1 walked the perimeter of the community and at approximately 8:56 p.m., R1 knocked on the front door and re-entered the community. Staff were unaware that R1 was out of the community. A body assessment was conducted, and no injuries were noted on R1. Per interviews and video survelliance review, R1 walked around the perimeter of the community for 80 minutes. The facility is equipped with Wanderguard, yet R1 does not wear a Wanderguard.
Prior to the on-site visit, this community submitted an incident report, the staff schedule for the evening of 4/25/2021, and the community’s elopement protocols. During today’s visit, the LPAs spoke with the Executive Director, obtained copies of R1’s physician’s report, appraisal and staff training materials, and conducted an exterior physical plant tour at 10:50 a.m.

Based on interview and record review, the facility does status checks of residents every two hours. Hence, the resident could have left after a successful status check. In addition, staffing was sufficient at the time of the incident. Yet, the Administrator confirmed that the egress connection for the service door was inoperable at the time of the incident. Thus, that is why R1 was able to egress without triggering an alarm. It is unknown as to how long the egress for the service exit was inoperable prior to R1 exiting on 4/25/2021, as any resident could have used this door without triggering an alarm. However, the egress connection was repaired on 4/26/2021. The egress was operable at the time of today’s visit. After this incident, an in-service training on Elopement Protocols and Procedures was held. Copies of the training documents were obtained.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's report and appeal rights were reviewed and issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: SILVERADO THOUSAND OAKS, LLC
FACILITY NUMBER: 565850072
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/06/2021
Section Cited

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87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times.
This requirement is not met as evidenced by:
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Based on interview, the licensee did not comply with the section cited above, as the egress connection for the service door was inoperable, as R1 left the facility without triggering an alarm, which poses an immediate health and safety risk to residents in care.
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Deficiency Dismissed
Type A
05/06/2021
Section Cited

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87464(f)(1) Basic Services. (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement is not met as evidenced by:
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Based on interview and records review, the licensee did not comply with the section cited above, as the facility failed to ensure that all exits were secure to prevent elopements, which poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2021
LIC809 (FAS) - (06/04)
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