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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850072
Report Date: 02/14/2024
Date Signed: 02/14/2024 04:34:15 PM


Document Has Been Signed on 02/14/2024 04:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:SILVERADO THOUSAND OAKS, LLCFACILITY NUMBER:
565850072
ADMINISTRATOR:SABRINA PEGROSSFACILITY TYPE:
740
ADDRESS:980 WARWICK AVETELEPHONE:
(805) 307-7300
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:82CENSUS: 49DATE:
02/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Sabrina PegrossTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent Case Management - Incident visit regarding a self-reported incident which took place on 2/9/2024. LPA met with the facility Administrator Sabrina Pegross and explained the reason for the visit.

On 2/9/2024, at approximately 8:15 a.m., Resident 1 (R1) was receiving assistance from Staff 1 (S1). S1 was observed to handle Resident 1 (R1) roughly, slap R1, grab R1 by the neck and shoulder, verbally threaten R1, and push R1 in the hallway. The Ventura County Sheriff's Office was called and ultimately arrested S1.

During LPA's visit today, 2/14/2024, LPA interviewed staff at 9:10 a.m., 9:25 a.m., 9:49 a.m., 10:06 a.m., 10:19 a.m., and 11:21 a.m.

The Administrator stated they are still working with their IT department to get a copy of the video they captured in the hallway of part of the incident. They will forward the video to the Sheriff and CCL once they are able to get it copied.

LPA may need to return at a later date regarding this incident. No deficiencies were observed. A copy of the report was issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
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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