565850072-11-28-2023-29-AS-DPEA-CY42US-20231130164250

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850072
Report Date: 11/28/2023
Date Signed: 11/28/2023 03:29:23 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
11/21/2023 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20231121120147

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: 45	DATE:	11/28/2023
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Sabrina Pegross - Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility Staff did not follow proper reporting requirements.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint visit to investigate the allegation listed above. Upon arrival LPA met with Administrator Sabrina Pegross and explained the reason for the visit.
At approx. 10:30am, LPA conducted physical plant, interviewed staff and reviewed and obtained copies of pertinent documentation relevant to the investigation.

It was reported that, Facility Staff did not follow proper reporting requirements as it was alleged that Resident #1 (R1)'s responsible party requested a written report pertaining to an incident that occurred on 10/29/2023. Interviews conducted and records review reflected that the facility had self-reported an incident to the Department on 10/30/2023, which stated that on 10/29/2023, R1 and Resident #2 (R2) were involved in a verbal altercation, and R1 stated that R2 had slapped them on the back of the head. Staff separated both R1 and R2 and no further incident or injuries were noted. The incident report also indicated that R1's responsible party and MD were notified of the incident.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

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 3

Control Number 29-AS-20231121120147

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: 11/28/2023

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

Continued from 9099

On 10/30/2023, Staff #1 (S1) called R1's responsible party and informed them of the incident that had occurred . Additionally , on 10/30, R1's responsible party visited R1 at the facility and spoke with Staff #2 (S2) and Staff #3 (S3) in person in regards to the incident. On 11/17/2023, the responsible party requested a detailed written report of the incident. S1, S2 and S3 verbally provided the responsible party with detailed information of the incident on 10/30, however a written report has not been provided to R1's responsible party as of 11/28/2023. Based on information gathered during the course of the investigation, the Department has sufficient evidence to support the allegation of Facility staff did not follow proper reporting requirements. Therefore, this allegation has been deemed Substantiated at this time.

The following deficiencies were observed (See LIC 9099-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 appeal rights discussed and a copy of the report was provided to Administrator.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20231121120147

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: 11/28/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 12/08/2023 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	87211(a)(1)(D) - Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee agreed to provide R1's responsible party with written report of incident that occurred on 10/29/2023 and review regulation cited and provide a statement of understanding to CCL via email by EOD 12/08/2023.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not comply with the section cited above, as R1's responsible party was not provided a written report of incident that occurred on 10/29, which poses a potential health, safety and personal rights risks to residents in care.	8 9 10 11 12 13 14
	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.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3