565850072-10-2-2025-29-AS-KDUK-DM3QMC-20251002121718

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850072
Report Date: 10/02/2025
Date Signed: 10/02/2025 12:17:36 PM

Document Has Been Signed on 10/02/2025 12:17 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, LLC		FACILITY NUMBER:	565850072
ADMINISTRATOR/ DIRECTOR:	ROBLOE BABASANTA		FACILITY TYPE:	740
ADDRESS:	980 WARWICK AVE		TELEPHONE:	(805) 307-7300
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY: 82		CENSUS: 43	DATE:	10/02/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Robloe (Rob) Babasanta		TIME VISIT/ INSPECTION COMPLETED:	12:25 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit at 10:30AM. The LPA met with Administrator Robloe (Rob) Babasanta and Director of Health Services Heather Hampel and explained the reason for the visit. Entrance interview conducted.

The Department received a self-reported incident and a subsequent death report regarding Resident #1 (R1) on 09/15/2025. LPA requested documents for R1 be sent via email, which were received on 09/24/2025. Incident report indicates R1 was taking a walk with facility staff when R1 experienced chest pain and began to collapse. 9-1-1 was called and paramedics continued CPR, however R1 was pronounced deceased.

During today’s visit, LPA conducted a brief physical plant tour to ensure there are no immediate health and safety concerns, conducted in-person interviews with Administrator and Director of Health Services and LPA obtained copies of pertinent documents relevant to the incident. Record review revealed R1 had a diagnosis of chronic atherosclerosis of aorta. Interview revealed about a week prior to the incident, R1 had visited the hospital and was medically clear to return to the facility. R1 had returned to regular activities and enjoyed taking walks multiple times a day. On the date of the incident, staff was with R1 when R1 collapsed, staff assisted R1 and began cardiopulmonary resuscitation (CPR.) Paramedics arrived and continued CPR, however, R1 was pronounced deceased. Following R1’s death, Administrator continued to communicate with R1’s family. Administrator provided LPA with email communication, which indicates R1’s cause of death was listed as “cardiac tamponade secondary to ruptured aortic aneurysm.” R1’s death was listed as natural.

No citations issued. Should further investigation be warranted, LPA will return at a later date.

Exit interview conducted. Report was reviewed and a copy was provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Kelly Dulek
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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