565850072-5-31-2024-29-AS-KHEN-D5STJN-20240531144637

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850072
Report Date: 05/31/2024
Date Signed: 05/31/2024 12:34:05 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
02/28/2024 and conducted by Evaluator Teresa Camara

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20240228102452

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: 46	DATE:	05/31/2024
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Rob Babasanta		TIME COMPLETED:	12:55 PM

ALLEGATION(S):

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Physical Abuse - Resident #1 (R1) was physically and emotionally injured by Staff #1 (S1) while under the care and supervision of the facility.
Conduct Inimical - Staff #1 (S1) was arrested and charged with misdemeanor elder abuse and being under the influence of a controlled substance.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Administrator Rob Babasanta and explained the reason for the visit.

On 02/28/2024, the Department received a complaint regarding allegations of physical abuse and conduct inimical. Resident #1 (R1) was physically and emotionally injured by Staff #1 (S1), while under the care and supervision of the facility; and S1 was arrested and charged with a misdemeanor elder abuse and being under the influence of a controlled substance. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Philippe Ryan Miles.

(continued on LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

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 5

Control Number 29-AS-20240228102452

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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, LLC	FACILITY NUMBER: 565850072
	VISIT DATE: 05/31/2024

NARRATIVE

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(continued from LIC9099)

It was noted that the incident was self-reported by the facility on 02/09/2024. Licensing Program Analyst (LPA) Teresa Camara conducted two Case Management visits regarding the incident on 02/12/2024, from 9:32am to 11:45am and on 02/14/2024, from 9:09am to 1:20pm. During the visits, LPA Camara met with the Administrator, reviewed and obtained records, toured the facility, conducted staff interviews, and attempted to interview R1. The LPA also reviewed a video of the incident. The incident report documented that on 02/09/2024, at approximately 8:15am, Resident #1 (R1) was receiving assistance from Staff 1 (S1). S1 was observed to handle 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.

On 02/29/2024, from 9:20am to 10:30am, LPA Camara conducted an initial complaint investigation visit and health and safety check. The LPA met with co-Administrator Rob Babasanta and explained the reason for the visit. At 9:40am, the LPA requested and obtained documents. At 9:45am, the LPA conducted a physical plant tour. The LPA advised that further investigation would be conducted by Community Care Licensing Division (CCLD) Investigations Branch (IB) Investigator Philippe Ryan Miles.

On 04/22/2024, from approximately 10:56am to 1:32pm, Investigator Miles attempted to conduct an interview with R1 (who was unable to be interviewed due to diagnosis of advanced dementia/Alzheimer’s disease/unable to communicate), conducted interviews with Administrator, Director of Health Services, and Staff #1 (S1); on 05/03/2024, 05/14/2024, and 05/20/2024, attempted to interview former Staff #2 (S2), and left voice messages. In addition, Investigator Miles reviewed Superior Court of California, County of Ventura VCIJIS Case#: 202403859 court documents, Ventura Sheriff’s Department VSD Report#: 2024-16948, facility surveillance video, and facility file documents pertaining to the investigation.

(continued on LIC9099-C page 3)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 29-AS-20240228102452

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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, LLC	FACILITY NUMBER: 565850072
	VISIT DATE: 05/31/2024

NARRATIVE

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(continued from LIC9099-C page 2)

According to the incident report submitted by the facility, on 02/09/2024, at approximately 8:15am, S1 assisted R1 while changing R1’s clothes. S2 walked in to assist S1 who became aggressive towards R1. R1 spat on S1, who then aggressively pulled R1’s pants down. S1 pushed R1 to a seated position on the bed. R1 slapped S1. S1 slapped R1 in the face, “grabbed R1’s face and demanded R1 apologize.” S2 requested S1 to move away and would take care of R1. While S2 was assisting R1, S1 had their arm on R1’s neck and shoulder. S1 “was saying you think you are stronger than me.” S2 told S1 to leave the room. R1 went outside the room to sit down on the bench. R1 did not want to go with S1 who began pulling R1 down the hallway causing R1 to almost lose balance. Staff reported the incidents to management.

The investigation revealed that due to the incident on 02/09/2024, R1 sustained a small, fresh laceration to their left arm. The laceration was approximately one centimeter in length and drew blood. During the VSD interview and evaluation of S1, Deputy Barrios observed signs and symptoms of S1 “being under the influence of a controlled substance.” S1 displayed “pinpoint pupils in indoor lighting, was extremely fidgety, and was not able to provide an accurate or chronological sequence of events from start to finish. S1’s statements were fragmented and while S1 spoke, the deputy observed a “very visible and pronounced neck pulse.”

S1 denied covering R1’s mouth, grabbing the back of neck, or using S1’s forearm to push R1 down to the bed. S1 stated they placed their hand near R1’s mouth to prevent R1 from spitting on S1, but “was adamant that at no time did they (S1) cover R1’s mouth.” S1 stated S1 assisted R1 down the hallway to the dining hall but was not “dragging” R1 “rather [than] assisting R1 with R1’s movement using S1’s body weight.”

A review of the video surveillance showed S1 “mistreating, dragging, taunting, slapping, and air kicking” R1 in the hallway. The VSD conducted an investigation and the VSD arrested S1 and transported S1 to the Pre-Trial Detention Facility (PTDF) where S1 was booked for PC 368(b)(1) for Elderly Abuse and HS 11550(a) for Under the Influence of a Controlled Substance.

(continued LIC9099-C page 4)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 29-AS-20240228102452

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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, LLC	FACILITY NUMBER: 565850072
	VISIT DATE: 05/31/2024

NARRATIVE

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(continued from LIC9099-C page 3)

On the allegation “Physical Abuse – Resident #1 (R1) was physically and emotionally injured by Staff #1 (S1) while under the care and supervision of the facility” – On 02/09/2024, the day of the allegation, S2 reported to the Director of Health Services, that S2 witnessed S1 physically abuse R1 while changing R1’s soiled clothing. According to Ventura Sheriff’s Department (VSD) Report#: 2024-16948, S2 told the deputies S2 witnessed S1 slap R1 on the face, and actively applied pressure using S1’s forearm against R1’s chest while on R1’s bed. The Director of Health Services showed the captured surveillance video to the deputies of S1 “mistreating, dragging, taunting, slapping, and air kicking” R1. The VSD arrested S1 and transported S1 to the Pre-Trial Detention Facility (PTDF) where S1 was booked for PC 368(b)(1) for Elderly Abuse and HS 11550(a) for Under the Influence of a Controlled Substance. S1 claimed S1 did not physically abuse R1. Based on the interviews conducted, supporting documents, and video surveillance; there is sufficient evidence to support the allegation of Physical Abuse. Therefore, the allegation is deemed Substantiated at this time.

On the allegation “Conduct Inimical – Staff #1 (S1) was arrested and charged with misdemeanor elder abuse and being under the influence of a controlled substance” - On 02/09/2024, the day of the allegation, when the VSD was at the facility questioning S1 regarding R1, the VSD Deputy observed signs and symptoms of S1 “being under the influence of a controlled substance.” During the evaluation of S1’s urine sample collected, S1 tested “presumptive positive for amphetamines and opiates.” S1 was transported to the Pre-Trial Detention Facility (PTDF) where S1 was booked for PC 368(b)(1) for Elderly Abuse and HS 11550(a) for “Under the Influence of a Controlled Substance.” Based on the fact that S1 tested positive for being under the influence while working at the facility, there is sufficient evidence to support the allegation of Conduct Inimical; therefore, the 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 1569.49(f).

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D).
Exit interview conducted, appeal rights discussed, and a copy of this report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20240228102452

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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, LLC	FACILITY NUMBER: 565850072
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/31/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/07/2024 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... This requirement was not	1 2 3 4 5 6 7	Licensee will submit a plan how they will ensure the personal rights of residents are not violated. Submit to CCL by 6/7/2024.
	8 9 10 11 12 13 14	met as evidenced by: Based on interviews, records review, and video surveillance review, the licensee did not comply with the section cited above. Video surveillance showed S1 “mistreating, dragging, taunting, slapping, and air kicking” R1, which posed an	8 9 10 11 12 13 14	immediate health and safety risk to residents in care.
Type A 06/03/2024 Section Cited HSC 1569.58(a)(2)	1 2 3 4 5 6 7	§1569.58 Persons prohibited from being a licensee, owning beneficial interest in licensed facility, or holding certain positions or employment; grounds; notice; removal; appeal; petition for reinstatement (a) The department may prohibit from employing, or continuing the employment of, ...any	1 2 3 4 5 6 7	S1 was terminated by the facility. S1 was charged with HS 11550(a) for Under the Influence of a Controlled Substance. Plan of correction complete.
	8 9 10 11 12 13 14	employee, prospective employee, or person who is not a client and who has done any of the following: (2) Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the State of	8 9 10 11 12 13 14	California. This requirement is not met as evidenced by: Based on drug testing results, the licensee did not comply with the section cited above. S1 tested positive for being under the influence of a controlled substance while working at the facility, which posed an immediate health and safety risk to residents in care.

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) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

LIC9099 (FAS) - (06/04)

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