565850072-8-1-2023-29-AS-ASMH-CUAQ4J-20230801115026

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850072
Report Date: 08/01/2023
Date Signed: 08/01/2023 11:51:28 AM

Document Has Been Signed on 08/01/2023 11:51 AM - 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:	SILVERADO THOUSAND OAKS, LLC		FACILITY NUMBER:	565850072
ADMINISTRATOR:	STEPHANIE FUNDERBURG		FACILITY TYPE:	740
ADDRESS:	980 WARWICK AVE		TELEPHONE:	(805) 307-7300
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	82	CENSUS: 55	DATE:	08/01/2023
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Stephanie Funderburg		TIME COMPLETED:	11:45 AM

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Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management /Non-Compliance visit. The purpose of today’s visit was to ensure the facility was maintaining substantial compliance as discussed in the Non-Compliance Conference that took place on 10/26/2022. The licensee is placed on frequent monitoring for a period of two years. The LPA met with staff and explained the reason for the visit. The last case management visit was on 05/15/2023.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations.

Snacks and refreshments are available for residents in the Bistro and dining rooms. Dining room furniture on both floors appeared to be in good condition. There were no obstructions and/or tripping hazards throughout the facility. The facility maintains a comfortable temperature. Fire extinguishers were charged and last serviced within the past twelve (12) months. Planned activities are offered. Activity schedule is posted throughout the facility. The LPA observed staff engaging residents in group activities. All activity rooms and common spaces appeared clean and in good repair. The facility has several enclosed courtyards with appropriate outdoor seating for resident use. There were no bodies of water observed.

RESIDENT ROOMS: The LPA observed eight (8) rooms, and rooms were furnished with clean linens, furnishings and lighting. Restrooms were observed with properly installed grab-bars in resident bathrooms and non-skid strips in shower tubs. Out of the eight (8) rooms, the LPA found that there were five (5) rooms in which personal care and hygiene items were accessible and unlocked: Room 109, 123, 133, 203, 232.

FILES: The LPA reviewed the files of the five (5) resident that had personal care and hygiene items accessible in their rooms. Out of the five (5) files reviewed, the LPA reviewed physician’s reports and identified that there were two (2) residents (Resident #1 – R1, Resident #2 – R2). that are deemed at risk if they have access to personal care items. During the physical plant tour, which took place from 9:35 a.m. – 10:00 a.m., personal care items were accessible and unlocked in the rooms of R1 and R2.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

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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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
	VISIT DATE: 08/01/2023

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The LPA reviewed a selection of staff files to verify adequate training hours as detailed in Health & Safety Code 1569.625. The LPA was unable to confirm the completed hours of the five (5) staff, nor the completed training topics as detailed in regulation. Staff indicated that they verified that care staff completed training through the completion of quizzes, however the quizzes did not detail the number of the hours completed. In addition, the quizzes did not cover all of the topics as required in regulation.

INFECTION CONTROL: Upon entry into the facility, the LPA was notified that the facility had three (3) confirmed COVID-19 positive cases as of 07/31/2023. The Executive Director indicated that they would report these cases to the local health department and submit the required incident reports.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/01/2023 11:51 AM - It Cannot Be Edited

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: 08/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/01/2023 Section Cited CCR 87705(g)(1)	1 2 3 4 5 6 7	87705(g)(1) Care of Persons with Dementia. … Residents with dementia shall be allowed to keep personal grooming and hygiene items … unless there is evidence to substantiate that the resident cannot safely manage the items.	1 2 3 4 5 6 7	The Administrator agreed to the following: 1. Secure the items by the end of the day. Inform CCL when this has taken place 2. Conduct an in-service training with care staff, regarding items that shall be inaccessible to residents with dementia.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply in the section cited above for two out of five residents (R1, R2), which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Submit sign-in sheet no later than 8/11/2023. Submit POC to CCLASCPWoodlandHillRO@dss.ca.gov, ATTN: Officer of the Day
Type B 08/11/2023 Section Cited HSC1569.625(b)(1)	1 2 3 4 5 6 7	1569.625(b)(1) Staff training; legislative findings; contents: ...Staff...who assist residents ... to receive appropriate training. This training shall consist of 40 hours of training …. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator has agreed to do the following: 1. Submit a Plan of Action, detailing how the facility will comply with regulatory standards as it pertains to training topics and documentation
	8 9 10 11 12 13 14	Based on record review and interview, the licensee did not comply with the section cited above in 5 out of 5 staff files, as training could not be verified as required, which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	Submit Plan of Action no later than 8/11/2023. Submit POC to CCLASCPWoodlandHillRO@dss.ca.gov, ATTN: Officer of the Day

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 Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

LIC809 (FAS) - (06/04)

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