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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850072
Report Date: 08/23/2024
Date Signed: 08/23/2024 04:24:07 PM

Document Has Been Signed on 08/23/2024 04:24 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:SILVERADO THOUSAND OAKS, LLCFACILITY NUMBER:
565850072
ADMINISTRATOR/
DIRECTOR:		SABRINA PEGROSSFACILITY TYPE:
740
ADDRESS:980 WARWICK AVETELEPHONE:
(805) 307-7300
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 82CENSUS: 49DATE:
08/23/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:43 AM
MET WITH:Robloe (Rob) Babasanta & Heather HampelTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct an annual continuation visit. Upon arrival, the LPA met with Executive Director Robloe (Rob) Babasanta. Entrance interview conducted.

This visit and related report serve as both the annual continuation and legal non-compliance visit. The licensee was placed on frequent monitoring for a period of two years during a Non-Compliance Conference that took place on 10/26/2022. The last facility visit was conducted on 03/29/2024.

PHYSICAL PLANT: Beginning at 11:25AM, the LPA and the Executive Director briefly toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. During facility tour, staff were observed engaging with residents in activities. LPA spoke with various residents throughout the facility tour and no concerns were observed nor communicated.

Fire extinguishers throughout the community were observed to be fully charged and last serviced 07/15/2024. Annual fire protection inspection was conducted by Smart Systems Technologies Incorporated on 06/10/2024. Proof of correction for 2 items noted as deficient was provided to the LPA.

FILES: Beginning at 11:50AM, the LPA reviewed 5 (five) resident files for but not limited to: physician's report, needs and service appraisals, personal rights. All 5 (five) resident files reviewed contained all required documents.

Beginning at 12:27PM, The LPA reviewed a selection of 5 (five) staff files for documents including, but not limited to health screening, TB test results, background clearance, and training records. All staff records reviewed were observed to be complete and in compliance with regulation at this time.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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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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: 08/23/2024
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infection control plan and the facility's emergency disaster plan. The facility's policies and procedures as it pertains to infection control are adequate. LPA reviewed the facility's emergency disaster plan, which was observed to be complete and updated annually as required. The facility conducts emergency disaster drills on each shift quarterly, with the last fire drill documented on 07/16/2024.

MEDICATION REVIEW: Began at 02:31PM, LPA and Director of Health Services Heather Hampel reviewed medications for 5 (five) residents. All 5 (five) of 5 (five) residents' medications reviewed were stored and documented in compliance with regulation at the time of the visit.

INTERVIEWS: Throughout today's visit, LPA interviewed 3 (three) staff and multiple residents. No concerns were noted.

DOCUMENTS OBTAINED: During today's visit, LPA obtained a copy of the facility's liability insurance and staff schedule.

No citations issued. Exit interview conducted. A copy of today's report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC809 (FAS) - (06/04)
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