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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850072
Report Date: 11/01/2024
Date Signed: 11/01/2024 06:03:39 PM

Document Has Been Signed on 11/01/2024 06:03 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:
ROBLOE BABASANTAFACILITY TYPE:
740
ADDRESS:980 WARWICK AVETELEPHONE:
(805) 307-7300
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 82CENSUS: 49DATE:
11/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:10 PM
MET WITH:Heather Hampel & Robloe (Rob) BabasantaTIME VISIT/
INSPECTION COMPLETED:
06:08 PM
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Licensing Program Analyst (LPA) Kelly Dulek conducted a Case Management - Incident visit regarding a self-reported incident which took place on 11/01/2024. LPA met with the facility Director of Health Services Heather Hampel and explained the reason for the visit.

LPA Dulek received a telephone call/voicemail from Administrator Robloe (Rob) Babasanta at 12:06PM on 11/01/2024. LPA returned Administrator's call and spoke with ED Babasanta and Heather Hampel via telephone at 02:30PM. Administrator indicated there had been an incident at the facility involving 2 (two) residents at the facility, who are roommates. On 11/01/2024, at approximately 04:30AM, facility staff discovered Resident #1 (R1) in the facility common area; R1 appeared agitated and had blood on their body. Facility staff called 9-1-1. Both Ventura County Fire and Ventura County Sheriff's Office responded at 04:44AM. Staff then discovered Resident #2 (R2) was injured in the room R1 and R2 shared. Ventura County Fire tended to R2, who was subsequently pronounced deceased at the facility. Ventura County Sheriff detained R1 related to the incident.

During LPA's visit today, LPA interviewed Director of Health Services (DHS) at 03:12PM, toured the facility with DHS at 03:19PM and LPA obtained copies of pertinent documents. No immediate health and safety hazards were identified during facility tour.

Facility management was informed that this incident was referred to Community Care Licensing Division's Investigations Branch (IB). LPA and/or IB Investigator will return at a later date regarding this incident.

No deficiencies cited during today's visit. Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2024
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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