565850072-11-2-2023-29-AS-DPEA-CY3LW7-20231130080636

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850072
Report Date: 11/02/2023
Date Signed: 11/02/2023 03:32:16 PM

Unsubstantiated

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
10/31/2023 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20231031082743

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: 53	DATE:	11/02/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Sabrina Pegross		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff did not adequately supervise residents, resulting in a resident hitting another resident while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Martha Arroyo arrived unannounced to conduct an initial complaint visit for the above allegation. Upon arrival, the LPA met with Executive Director (ED) Sabrina Pegross and Director of Health Services (DHS) Heather Hampel and the reason for the visit was explained. Entrance interview conducted.

During today's visit, the LPA along with the ED and DHS conducted a tour of the facility to ensure there are no health and safety concerns at 12:20 p.m., conducted interviews with four staff and five residents between 12:35 p.m. and 2:50 p.m., conducted a file review at 11:45 a.m., and obtained copies of the census, staff schedule, and other pertinent documents relevant to the investigation.

(Report Continued on LIC 9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20231031082743

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: 11/02/2023

NARRATIVE

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(Report Continued from LIC 9099...)

Regarding the allegation: Staff did not adequately supervise residents, resulting in a resident hitting another resident while in care. It was reported that Resident #1 (R1) was hit in the head by Resident #2 (R2) and facility staff did not report altercation. Record review revealed the facility had self-reported incident to the Department on 10/30/2023 regarding incident that had occurred on 10/29/2023. Incident report stated that at approximately 8:30 p.m., staff were in the dining room when they heard a loud noise coming from the living room. When staff went to see what was going on, they found R1 and R2 arguing. R1 stated R2 had slapped them on the back of the head. R2 admitted to tapping R1 on the head. Both R1 and R2 were separated, and no further incident or injuries were noted. Additionally, R1 and R2 were roommates before incident; however, after the incident, residents have been moved to separate bedrooms. Information obtained and reviewed revealed R1 was admitted to the facility on 08/29/2023 and R2 was admitted to the facility on 04/08/2023. A review of R1’s physicians report dated 08/30/2023, listed R1’s primary diagnosis as dementia and identified R1 as confused/disoriented; however, is not aggressive and is able to follow instructions and communicate their needs. Additionally, a review of R2’s physicians report dated 02/06/2023, listed R2’s primary diagnosis as dementia and type 2 diabetes and identified R2 as confused/disoriented with no inappropriate or aggressive behaviors. Interviews conducted with staff revealed prior to this incident, there had not been other incidents that involved R1 and R2. Staff stated R1 had forgotten about the incident occurring shortly as well. Interview conducted with a family member revealed that they have not had any issues with the supervision facility staff is providing the residents. Interviews with residents revealed there is staff present all around and reported feeling safe. Further interviews revealed five out of five residents did not express any concerns about living at the facility. Based on the information gathered during the course of the investigation, the Department does not have sufficient evidence to support the allegation of ‘staff did not adequately supervise residents, resulting in a resident hitting another resident while in care’. Therefore, this allegation is being deemed Unsubstantiated at this time.

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

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC9099 (FAS) - (06/04)

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