565850072-11-4-2024-29-AS-ZCHN-DAPP5W-20241104100126

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850072
Report Date: 10/24/2023
Date Signed: 11/04/2024 10:03:03 AM

Document Has Been Signed on 11/04/2024 10:03 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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: 52	DATE:	10/24/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:29 PM
MET WITH:	Sabrina Pegros		TIME COMPLETED:	05:30 PM

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	Licensing Program Analyst (LPA) Zabel Chochian conducted a Case Management - Incident visit at the facility today to follow up on incident reports received 10/23/23. The LPA met with Executive Director (ED) Sabrina Pegros and explained the reason for the visit. Following was discussed with the ED from approximately 2:45pm-3:45pm. On 10/23/2024, the Department received a self reported incident from this facility regarding an incident pertaining to staff. On 10/16/23, an associate file audit was conducted by the facility and associate statements pertaining to Staff #1's interaction with residents was discovered. Staff #1 was placed on suspension on 10/17/2023 pending internal investigation by facility. On 10/20/23, staff interviews were conducted at the community with individuals who work with staff #1. There were reports that staff #1 was being forceful with residents when administering medication; alleged abuse and also reports of attitude and demeaning comments made to residents. ED mentioned that calls were placed to former ED Stephanie Funderburg and former Director of Health Services Hope Langston who were employed at the community when the initial reports were made however no response received at this time. Current ED reported that based on their internal investigation staff #1 will not be returning to the community and will officially be terminated as of 10/25/2023. ED stated that they have started In-service on mandated reporting and resident abuse training with staff and will complete in-service with all staff by 10/26/2023. LPA reviewed staff files from 4-5:15pm; LPA gathered copies of record for further review/investigation into the alleged abuse mentioned above. Additional incident reports were discussed with current ED. Two (2) separate incidents regrading client to client aggression was reported to the department. First incident reported occurred on 10/21/2023 in the morning at 8AM - Resident #1 pushed Resident #2's wheelchair and it flipped backwards; resident #2 sustained a skin tear on the left ear; resident #2 was provide immediate medical attention. (cont.to LIC809c)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/24/2023

NARRATIVE

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Resident #1 was redirected. Second incident occurred on 10/21/2023 in the evening at approximately 7:45pm - resident #3 swung walker and struck resident #4's head (0.5cm abrasion noted above left eye). According to current ED in both incidents staff was present and redirected residents and immediate medical attention was provided. LPA requested that the incident reports be resubmitted with the additional details.

Current ED reported that the staffing ratio is 1:9; there are six (6) caregivers and one (1) charge nurse/med-tech on duty for each shift (AM/PM); private companions are also assigned to some residents requiring one on one. Current ED mentioned that if staff call out they always fill behind any call outs through the staffing agency. Current ED reported that the facility staffing ratio is sufficient at this time.

No deficiencies issued at this time. Exit interview conducted. A copy of the report provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC809 (FAS) - (06/04)

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