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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850072
Report Date: 12/23/2024
Date Signed: 12/23/2024 04:06:56 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/14/2023 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20230914154258
FACILITY NAME:SILVERADO THOUSAND OAKS, LLCFACILITY NUMBER:
565850072
ADMINISTRATOR:STEPHANIE FUNDERBURGFACILITY TYPE:
740
ADDRESS:980 WARWICK AVETELEPHONE:
(805) 307-7300
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:82CENSUS: 46DATE:
12/23/2024
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Rob BabasantaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident care needs not met.
Staff did not initiate meeting with resident's responsible person.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced subsequent complaint visit to this facility to deliver investigation finding. LPA met with Executive Director and reason for the visit was stated.

On 09/14/2023, Community Care Licensing Division (CCLD) received a complaint with the above allegations. On 9/20/2023, investigation was initiated from approximately 10:30am – 2pm; records were reviewed; interview was conducted with potential witnesses, and staff; ten (10) random resident rooms and common areas were toured. Attempt was made to interview residents during the room inspection.

Following is a summary of the investigation findings:

Regarding allegations, “Resident care needs not met” and “Staff did not initiate meeting with resident's responsible person”– It was alleged that staff did not follow through in addressing R1’s change in condition. It was also reported that subsequent care plan meeting was never initiated by facility staff. (cont.to LIC9099c).
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 29-AS-20230914154258
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/23/2024
NARRATIVE
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Interview conducted with staff, potential witnesses and records reviewed revealed the following: R1 moved into this facility on 05/23/2022. A care plan meeting was initiated by facility staff on or about 06/10/2022 and another in 8/2022. Service plans completed by facility staff dated 5/25/2022; 05/31/2022; 09/06/2022; 11/03/2022; 11/30/2022; 03/21/2023 and 05/31/2023 were observed on file and reviewed. The Service Care Plans did not have any signatures to confirm who completed the evaluation and who was present during the evaluations. Potential witness interviewed revealed that beginning 10/2022 – 9/14/2023 several care plan meetings were initiated by R1’s responsible person due to the increasing decline observed in R1’s condition. On or about 07/13/2023, former Executive Director Stephanie Funderburg reported to R1’s responsible person that they would conduct a 72-hour behavioral mapping to address any issues or concerns. No documentation or record of this was found on file. On or around 09/07/2023, R1 was evaluated by Silverado team, and it was agreed to have R1 tested for possible UTI due to the increasing behavioral changes observed. On 09/13/2023, R1 sustained a fall. Interviews conducted revealed that the facility did not follow through with sending labs out for UTI test results. R1's responsible person was informed by former Director of Health Services - Hope Langston that the lab never picked up the urine sample. No further action was taken by facility. On 09/14/2023, R1's responsible person contacted the physician and reported the increased decline observed and current symptoms; R1 was transferred to the nearest ER per physician orders; R1 was admitted to Los Robles Hospital on 09/14//2023 – series of tests were conducted. R1 tested positive for UTI and chest x-ray indicated pneumonia.

Based on the above gathered, there is sufficient evidence to support the allegations; therefore allegations “Resident care needs not met” and “Staff did not initiate meeting with resident's responsible person”; is deemed Substantiated.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies cited (refer to LIC 809-D):

Exit interview conducted. A copy of the report and appeal rights provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20230914154258
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/27/2024
Section Cited
CCR
87466
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Observation of the Resident:The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.
This requirement is not met as evidenced by:
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Current Executive Director reported that the facility residents are observed and monitored regularly and any significant change is reported accordingly. Submit a written self certification of understanding the regulation cited and your plan to ensure future compliance.Copy of in-service due by 1/3/25.
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Based on interviews and records review, the licensee did not comply in the section cited above. Former resident (R1) was observed to be declining however eventually hospitilized on 9/14/2023 and tested positive for UTI and pneumonia.
This posed a potiential health and safety risk to residents in care.
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Type B
12/23/2024
Section Cited
CCR
87467(a)(3)
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Resident Participation in Decisionmaking: (a)(3) - Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative,if any appropriate facility staff, and a representative of the resident’s home
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Current Executive Director stated the facility policy is that the residents service care plans be reviewed every 6 months or sooner if there is a significant change in condition/hospitalization and signed by all parties involved in the meeting. According to new ED that is the procedure they follow currently.
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health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility.
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(3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident’s condition, or once every 12 months whichever occurs first...
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/14/2023 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20230914154258

FACILITY NAME:SILVERADO THOUSAND OAKS, LLCFACILITY NUMBER:
565850072
ADMINISTRATOR:STEPHANIE FUNDERBURGFACILITY TYPE:
740
ADDRESS:980 WARWICK AVETELEPHONE:
(805) 307-7300
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:82CENSUS: 46DATE:
12/23/2024
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Rob BabasantaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff left resident in soiled clothing.
Staff not keeping resident’s room free from odor.
Staff not keeping resident’s room clean.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced subsequent complaint visit to this facility to deliver investigation finding. LPA met with Executive Director and explained the reason for the visit.

On 09/14/2023, Community Care Licensing Division (CCLD) received a complaint with the above allegations. On 9/20/2023, investigation was initiated from approximately 10:30am – 2pm; records were reviewed; interview was conducted with potential witnesses, and staff; ten (10) random resident rooms and common areas were toured. Attempt was made to interview residents during the room inspection.

Following is a summary of the investigation findings:
Regarding allegations, “Staff left resident in soiled clothing; Staff not keeping resident’s room free from odor and clean”. It was reported that resident #1 (R1) was found multiple times in the same clothing which were dirty and smelly. (continue to LIC9099c).
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20230914154258
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/23/2024
NARRATIVE
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 Potential witness interviewed reported that R1 was observed in dirty and smelly clothing on several different occasions. Staff interviewed denied allegations and reported that all residents are assisted with dressing when needed. Staff reported that if a resident is observed with soiled clothing staff would attempt to change resident. Staff expressed that residents do have accidents daily and are changed and cleaned when observed. Staff expressed that if a resident becomes combative, they would give resident space and allow resident to calm down and not force resident to change. Staff reported that residents are not left unattended and are checked and cleaned regularly. Facility common areas, and random resident rooms were toured on 9/20/2023; and on 03/29/2024 during the annual inspection. During these visits, random resident rooms and common areas toured did not observe to be unkept and were odor free at time of visits. Other potential witnesses interviewed shared that the facility is kept clean, odor free and facility residents observed in the common areas to be clean and not with soiled clothing.

Based on the above gathered, although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegations “Staff left resident in soiled clothing; Staff not keeping resident’s room free from odor and Staff not keeping resident’s room clean” are deemed UNSUBSTANTIATED at this time.

Exit interview conducted and copy of report provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5