565850072-10-31-2023-29-AS-KDUK-CX5PUL-20231031113744

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850072
Report Date: 10/31/2023
Date Signed: 10/31/2023 11:37:51 AM

Document Has Been Signed on 10/31/2023 11:37 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:	SABRINA PEGROSS		FACILITY TYPE:	740
ADDRESS:	980 WARWICK AVE		TELEPHONE:	(805) 307-7300
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	82	CENSUS: 50	DATE:	10/31/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Sabrina Pegross & Heather Hampel		TIME COMPLETED:	11:40 AM

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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit for the purpose of following up on two (2) self-reported incidents that occurred on 10/25/2023 and 10/29/2023. LPA met with both Director of Health Services Heather Hampel and Administrator Sabrina Pegross. LPA explained the reason for today's visit. Entrance interview conducted.

On 10/27/2023 a Suspected Abuse Report was received via e-fax at the Woodland Hills Regional Office. LPA Emily Peraldi reviewed the document, which indicates that on 10/25/2023 staff found Resident #1 (R1) inside Resident #2 (R2)’s room. R1 was observed on the ground and bleeding, R2 had blood on their hands and an unplugged radio was observed nearby. LPA Peraldi called and spoke with Ms. Hampel regarding the report and requested that an Incident Report be submitted to CCLD. Incident report was received later that same day.

A second incident report was received on 10/30/2023 related to an incident that occurred between Resident #3 (R3) and Resident #4 (R4) on 10/29/2023. R3 and R4 were observed in the living room area engaged in a verbal altercation. R3 indicated that R4 had hit them, R4 admitted to hitting R3.

During today’s visit, LPA toured the facility with both Director of Health Services and Administrator at 09:50AM, reviewed and obtained copies of pertinent documents, took photographs, LPA observed both R1 and R2, and interviewed both managers throughout the visit.

Record review revealed that none of the residents involved in either incident have any documented aggressive behavior. Interview related to the incident involving R1 and R2 revealed that when staff found the residents, neither seemed agitated. R1 does tend to wander throughout the secure facility and at times into other resident rooms. R2 tends to keep to themselves and remains in their room most times. Neither R1 nor R2 were able to communicate what had happened inside R2’s room, and the door was shut at the time, so there were no additional witnesses to the incident. The incident occurred before dinner time and staff found both R1 and R2 when assisting residents to the dining room. Documents reviewed did not indicate that either

Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

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: 10/31/2023

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resident requires additional supervision. Although R1 did sustain injuries as a result of the incident, R1 returned to the facility the same day. As a result of the incident, the facility has been providing additional supervision for both residents. Documents reviewed for R3 and R4 indicate that there is no previous aggressive behavior for either resident. The residents were roommates at the time of the incident, but as a result of the incident, they are no longer roommates. Interview revealed that R4’s medication has been adjusted as well. Administrator reported that the facility staffing ratio is sufficient at this time.

No deficiencies issued at this time. Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

LIC809 (FAS) - (06/04)

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