<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850072
Report Date: 03/25/2025
Date Signed: 03/25/2025 04:56:10 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
11/05/2024 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20241105163045
FACILITY NAME:SILVERADO THOUSAND OAKS, LLCFACILITY NUMBER:
565850072
ADMINISTRATOR:ROBLOE BABASANTAFACILITY TYPE:
740
ADDRESS:980 WARWICK AVETELEPHONE:
(805) 307-7300
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:82CENSUS: 40DATE:
03/25/2025
UNANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:Robloe (Rob) BabasantaTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Neglect/lack of care & supervision – Resident 1 (R1) caused severe injuries to Resident 2 (R2) that led to the death of R2
Facility did not provide basic services to resident(s) in care
Facility did not reappraise resident(s) in care
Facility retained a resident that required a higher level of care
Facility staffing is inadequate
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Kelly Dulek, Emily Peraldi, and Quoc Huynh conducted a subsequent complaint visit with the purpose of delivering findings for the above listed allegations. LPAs met with Administrator Robloe (Rob) Babasanta at 10:00AM. Entrance interview conducted.

On 11/01/2024, LPA Dulek received a telephone call/voicemail from Administrator Babasanta at 12:06PM indicating an incident had occurred between two (2) residents at the facility. LPA spoke to Administrator and Health Services Director (HSD) on the telephone at 02:30PM. LPA arrived at the facility at 03:10PM to conduct a Case Management visit related to the reported incident. During the visit, LPA interviewed HSD at 03:12PM, LPA conducted a health and safety check tour of the facility at 03:19PM, and LPA reviewed and obtained copies of relevant documents. LPA then received a complaint related to the reported incident and conducted an initial complaint visit on 11/06/2024. During the visit, LPA interviewed Administrator and HSD,
Report Continued on LIC 9099-C (p. 2)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025
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 7
Control Number 29-AS-20241105163045
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: 03/25/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
as well as toured the facility and obtained copies of additional documents. On 11/14/2024, LPA, along with Long Term Care Ombudsman (LTCO) MaeRetha Coleman conducted a subsequent complaint investigation. During the visit, LPA and LTCO interviewed Administrator at 09:45AM and conducted a health and safety check tour of the facility at 10:38AM. Administrator was informed throughout the visits that the complaint was referred to Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Phillipe Ryan Miles for investigation. Investigator Miles obtained and reviewed copies of Ventura County Sheriff’s Office (VCSO) reports related to the incident. Investigator Miles also interviewed Administrator on 03/06/2025. Throughout the course of the investigation, LPA Dulek reviewed all documents and reports obtained. During today’s visit, LPA reviewed and obtained a copy of the Medication Administration Record (MAR) for Resident #1 (R1). The following was then determined:

Allegation: “Neglect/lack of care & supervision – Resident 1 (R1) caused severe injuries to Resident 2 (R2) that led to the death of R2:”
The complaint alleges that an incident occurred on the morning of 11/01/2024, which resulted in R2’s death. LPA Dulek received a telephone call on 11/01/2024. Administrator indicated to LPA that an incident had occurred between two (2) residents at the facility, which resulted in R2 passing away due to the injuries sustained. LPA conducted a case management visit on 11/01/2024; a written incident report was provided to the LPA during the visit. VCSO interviewed all staff working at the facility on the overnight shift when the incident occurred. Review of interviews revealed that during the overnight shift that took place from 10:00PM on 10/31/2024 to 06:30AM on 11/01/2024, Resident #1 (R1) was observed to be agitated. Initially, the facility charge nurse radioed for assistance in the shared room belonging to R1 and Resident #2 (R2) before midnight. Staff #1 (S1) and Staff #2 (S2), who were working as caregivers during the overnight shift responded to the call for assistance. R2 was non-ambulatory and required assistance with activities of daily living (ADLs) such as toileting and transfer assistance. R2 was attempting to get out of their bed at that time. S1 and S2 provided care to R2 and observed that R1 was awake and concerned with the commotion in their shared room. Staff reassured R1 that everything was okay before leaving the room. Around 03:30AM, staff saw R1 walking around the common areas. R1 had a staff radio in their hand, as well as the foot rest from a wheelchair. S1 and S2 attempted to calm R1 as R1 indicated they were hearing voices and seeing “somebody.” Staff indicated R1 was “inconsolable and agitated.” All 3 (three) staff working the overnight shift observed R1’s behaviors around 03:30AM. While two (2) Silverado staff walked away, leaving R1 in the common area, S1 agreed to walk R1 to their room and check the room for R1’s safety. R1 began swinging the wheelchair leg at S1, resulting in a scratch to S1’s left forearm. S1 was able to take the items from R1
Report Continued on LIC 9099-C (p.3)
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20241105163045
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: 03/25/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
and R1 returned to their room at that time. S1 stated that R1 was “acting very dangerous” and S1 was scared that R1 would hurt someone. S1 requested the charge nurse to administer a PRN (as needed) medication to R1, however the charge nurse indicated that sometimes the medication does not work and the MAR indicated the medication was not administered. Around 04:30AM, while S1 and S2 were continuing to assist other residents, S2 heard a noise from the upstairs bistro area. The charge nurse radioed and indicated R1 had broken an upstairs window, but everything was okay. Staff found R1 in the common area covered in blood. R1 was agitated and would not allow staff to get close enough to R1 to assess for injury. The nurse called 9-1-1 and both VCSO, fire department, and emergency medical personnel responded promptly. When VCSO had secured the area and was present with R1, facility staff left the common area to go check on R1’s roommate, R2. Facility staff found R2 lying in their bed severely injured. Emergency personnel assessed R2 and pronounced R2 deceased. The cause of death was determined to be blunt force trauma. VCSO arrested R1 for R1’s involvement in R2’s death. Staff interviews revealed that R1 had been acting dangerously earlier in the evening, including physically assaulting S1, yet staff allowed R1 to return to their shared room unsupervised, where R1 physically assaulted R2 resulting in the death of R2. Based on interviews and record review, the preponderance of evidence standard has been met. Therefore, the allegation above is deemed SUBSTANTIATED at this time.

Allegation: “Facility did not provide basic services to resident(s) in care:”


The complaint alleges the facility did not protect R2 from their roommate, which resulted in R2’s death. As described above, staff indicated that on the night of the incident, R1 was “acting very dangerously” and S1 stated they were scared that R1 would hurt someone. Staff employed by the facility were aware that R1 had a history of aggressive behavior, which had previously prevented R2 from receiving care based on R1’s behaviors. R1 had a known behavior of arming themselves with pieces of metal found around the facility. On the night of the incident, R1 believed there were vampires in the facility and was hearing voices. Review of R1’s MAR revealed that R1’s PRN Lorazepam, which was ordered twice a day as needed for agitation, was not administered at all from 10/28/2024 – 11/01/2024 even though staff interviewed stated R1’s agitation was “out of control” during that time period. Interview revealed that on the night of the incident when S1 requested the nurse administer R1’s PRN Lorazepam, the nurse indicated it “sometimes didn’t work” and the medication was not documented as administered. Around 03:30AM on 11/01/2024, R1 attacked S1 with a metal wheelchair footrest, resulting in injury to S1. Staff attempted to de-escalate R1 and had threatened to call the police due to R1’s behaviors. However, staff did not call police until after R1 broke the window upstairs and staff found R1 covered in blood. Staff interviewed stated that R2 would have been defenseless
Continued on LIC 9099-C (p.4)
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 29-AS-20241105163045
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: 03/25/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
during any attack due to their mental impairment, limited communication and non-ambulatory status, yet staff still allowed R1 to return to their shared room throughout the night. Staff did not provide any additional safety checks inside R1 and R2’s room, even though R1 was acting erratically and R2 was unable to get out of bed without assistance. Based on interview and record review, the preponderance of evidence standard has been met, therefore the allegation above is deemed SUBSTANTIATED at this time.

Allegation: “Facility did not reappraise resident(s) in care” and “facility retained a resident that required a higher level of care:”


Record review revealed that upon admittance to the facility, R1’s diagnoses included, but were not limited to Parkinson’s Disease, Unspecified Psychosis not due to a substance or known, and unspecified dementia with behavioral disturbance. During a care conference on 05/02/2024, it was noted that R1 had increased hallucinations in addition to delusions. At that time, R1 was residing in a private room on the first floor. Management indicated that the lower floor is geared toward higher-functioning residents with dementia diagnoses and the upstairs area is designated for more advanced dementia and residents who require additional ADL care. Staff interviews revealed that R1 was moved upstairs to a shared room on 06/27/2024. Following the move to the second floor, R1 was noted with increased anxiety and agitation particularly later in the day, however R1 had a lower dosage of PRN medication prescribed for agitation at that time. On 08/30/2024, facility staff sent a request to R1’s physician indicating “pt mood is unstable” and R1’s physician ordered blood work. R1 visited the emergency room on 09/13/2024 due to syncope, orthostatic hypotension and seizure. On 10/17/2024, R1’s physician ordered an increased dose of Lorazepam twice daily as needed for agitation. Additionally, R1’s behaviors had changed more in the days and weeks leading up to 11/01/2024. The facility did have a form for Behavior Mapping dated 10/22/2024, with indications of R1 being awake in their room or awake in the hallway during the overnight hours. R1 was noted to be “withdrawn,” “anxious,” or “pacing” at these times. Staff interviewed stated R1s agitation the last three (3) or four (4) days has been “out of control” and “not re-directable.” On the night of the incident, all staff working were aware that R1 was “acting very dangerous” prior to the incident occurring, however, staff did not inform management nor intervene by calling 9-1-1 when R1 attacked S1 earlier in the evening. R1’s care plan was dated 04/14/2024; no new reappraisal nor care plan was assessed based on the observed changes in R1’s behavior. R1 was seen by Behavioral Health on 10/31/2024 and noted with “major depressive disorder” and document indicates “no cognitive impairment noted.” Based on interview and record review, the preponderance of evidence standard has been met, therefore the allegations above are deemed SUBSTANTIATED at this time. Report Continued on LIC 9099-C (p. 5)
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20241105163045
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: 03/25/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: “Facility staffing is inadequate:”
The complaint alleges that on the overnight shift from 10/31/2024 to 11/01/2024, the facility did not have sufficiently trained staff present at the facility. Interview and staff schedule review revealed that during the overnight shift, there are typically two (2) care staff scheduled and one (1) charge nurse working. Interview with S2 revealed that rounds have been taking “a little bit longer” due to low staffing. On the overnight shift on 10/31/2024, the facility did have a charge nurse working but had only one (1) Silverado care staff available. As a result, the facility scheduled an outside-agency staff to work as the second caregiver. Staff #1 (S1) is employed through 1 Heart Caregiver Services and does not work directly for Silverado Senior Living. Interview revealed that S1 had filled in as a caregiver at Silverado multiple times prior to the night the incident occurred. When the LPA inquired about training for S1, management staff indicated they assumed S1 was trained through the caregiving agency. Management stated that since S1 is not directly employed by Silverado, Silverado does not conduct regular training for S1. Training records for S1 were reviewed during the investigation. S1 did have a 2-hour orientation with the caregiving agency but did not meet initial or ongoing training requirements as outlined in Title 22 regulation. Based on interview and record review, the preponderance of evidence standard has been met, therefore the above allegation is deemed SUBSTANTIATED at this time.

A $500 immediate civil penalty is assessed today. The Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and/or 1569.49(f).

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies are cited (refer to LIC9099-D).

Exit interview conducted, appeal rights discussed, and a copy of this report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20241105163045
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: 03/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
03/26/2025
Section Cited
CCR
87464(f)(2)
1
2
3
4
5
6
7
87464 Basic Services (f) Basic services shall at a minimum include: (2) safe and healthful living accommodations and services, as specified in Section 87307, Personal Accommodations and Services
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to reassess residents and ensure proper placement with roommates and implement appropriate safety measures for all residents in care. Statement of understanding will be sent to CCLD by POC due date.
8
9
10
11
12
13
14
Based on interview and record review, the facility did not comply with the above cited section, as facility staff did not keep R2 safe from R1, resulting in R2's death, which posed an immediate health and safety risk to persons in care.
8
9
10
11
12
13
14
Request Denied
Type A
03/26/2025
Section Cited
CCR
87463(a)
1
2
3
4
5
6
7
87463(a) The pre-admission appraisal ...shall be updated in writing as frequently as necessary...to note significant changes in condition...and to keep the appraisal accurate...shall be referred to as the reappraisal.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to reassess residents and ensure proper placement with roommates and implement appropriate safety measures for all residents in care. Statement of understanding will be sent to CCLD by POC due date.
8
9
10
11
12
13
14
Based on interview and record review, the licensee did not comply with the above cited section, as staff were aware R1's mental condition and behavioral expressions had changed, however, no reappraisal was completed, which posed an immediate health and safety risk to persons in care.
8
9
10
11
12
13
14
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: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20241105163045
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: 03/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
03/26/2025
Section Cited
CCR
87411(a)
1
2
3
4
5
6
7
87411 (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...the physical arrangements of the facility require such additional staff for the provision of adequate services.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to ensure all agency staff utilized at the facility has sufficient training. Administrator also agreed to provide training to all staff on the topics of appropriate de-escalation behaviors, early intervention techniques, and medication interventions. Training will be ongoing and
8
9
10
11
12
13
14
Based on record review and interview, the licensee did not comply with the section cited above, as the facility was short staffed and utilizing agency staffing, S1 was not trained per regulation, and staff did not act competently, which posed an immediate health and safety risk to persons in care.
8
9
10
11
12
13
14
statement of understanding related to training will be sent to LPA by POC due date.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7