<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850072
Report Date: 02/16/2022
Date Signed: 02/16/2022 12:49:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/21/2021 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20210721162508
FACILITY NAME:SILVERADO THOUSAND OAKS, LLCFACILITY NUMBER:
565850072
ADMINISTRATOR:WILKIN, RONDAFACILITY TYPE:
740
ADDRESS:980 WARWICK AVETELEPHONE:
(805) 307-7300
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:82CENSUS: 42DATE:
02/16/2022
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Ronda WilkinTIME COMPLETED:
12:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Due to lack of care and supervision, resident suffered a fall, resulting in injuries
Facility did not seek medical attention in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Ashley Smith conducted a subsequent complaint visit to the facility today. The LPA met with Executive Ronda Wilkin and explained the reason for the visit.

On 07/21/2021, the Department received a complaint, alleging that Resident #1 suffered a fall, yet was not taken to the hospital until the next day. Once hospitalized, R1 was found to have sustained several injuries, which included several rib fractures. Community Care Licensing Division’s Investigations Branch (IB) Investigator Dennis Seng was assigned to the case. On 07/23/2021, the LPA interviewed the Executive Director and requested documents. Investigator Deng reviewed medical records on 8/24/2021; reviewed police records on 8/23/2021; interviewed hospital staff on 9/14/2021; interviewed three staff and three residents on 9/17/2021; interviewed R1’s family member on 9/17/2021; interviewed staff from a collateral agency on 9/17/2021, 9/20/2021, and 9/21/2021; interviewed three former staff members on 10/14/2021; and, reviewed facility surveillance video. During today's visit, the LPA interviewed staff from 9:55 a.m. - 11:30 a.m.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022
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 6
Control Number 29-AS-20210721162508
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/16/2022
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
26
27
28
29
30
31
32
Regarding the allegation: Due to lack of supervision, resident suffered a fall, resulting in injuries
It was alleged that due to lack of care and supervision, R1 fell and sustained injuries. Interviews and a review of surveillance video revealed that on 7/16/2021, R1 was walking on the first floor with Staff #1 (S1) when R1 ran into an object inside the facility and fell over their walker. Interviews with S1 revealed that S1 believed they were approximately eight to ten feet behind R1 and alleged they kept their distance to ‘monitor’ R1. However, per the video surveillance footage of the incident, Investigator Seng concluded that S1 was approximately twenty (20) feet behind R1. In addition, video surveillance captured S1’s head facing downward towards a black object in their hand as R1 ambulated ahead of them. Due to the fall, R1 suffered lacerations to their face and a contusion to the right eye. Nursing staff believed that R1’s wounds were superficial, and placed steri-strips over R1’s wounds. Nursing staff, which included S1, ran neurological examinations throughout the night on R1 and determined that R1 did not require hospitalization.

The morning of 7/17/2021, R1 became agitated and ripped out the steri-strips and dug into their wounds, causing the wounds to reopen. Staff could not stop the bleeding, so R1 was sent to the hospital. A review of hospital paperwork revealed that R1 was diagnosed with recurrent falls, sinus bradycardia, right periorbital hematoma, scalp hematoma, and fractures. Discharge notes further documented old bruising to R1’s anterior chest wall into the right upper arm, signifying ‘old right-sided rib fractures’. Lastly, it noted ‘left anterolateral 6th and 7th rib fractures’ which were documented as ‘2 new rib fractures’.

Based on information obtained during the investigation, there is sufficient evidence to support the claim that due to lack of supervision, R1 suffered a fall, resulting in multiple injuries. Interviews with current and former staff, and staff from collateral agencies whom provided care for R1 noted that walking in a distance in excess of eight feet from R1 would not allow sufficient time for staff to intervene and take corrective action. Per the surveillance footage, S1 appeared to be distracted and the distance behind R1 appeared to be too significant for S1 to intervene. This allegation is deemed Substantiated at this time.


Regarding the allegation: Facility did not seek medical attention in a timely manner.
It was alleged that R1 should have been sent to the hospital following their fall the evening of 7/16/2021, as R1 struck their head. Staff interviews revealed that staff decided against sending R1 to the hospital as R1’s wounds appeared to be superficial, and nursing staff were monitoring R1 throughout the night.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20210721162508
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/16/2022
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
26
27
28
29
30
31
32
Interviews confirmed that staff placed steri-strips on R1’s wounds and assessed R1 thoroughly and were unable to identify any immediate health and safety concerns. R1 was then placed in their room and was monitored throughout the night.

The morning of 7/17/2021, R1 became agitated and ripped out the steri-strips and dug into their wounds, causing the wounds to reopen. Staff could not stop the bleeding, so R1 was sent to the hospital. A review of hospital paperwork revealed that R1 was diagnosed with recurrent falls, sinus bradycardia, right periorbital hematoma, scalp hematoma, and fractures. Discharge notes further documented old bruising to R1’s anterior chest wall into the right upper arm, signifying ‘old right-sided rib fractures’. Lastly, it noted ‘left anterolateral 6th and 7th rib fractures’ which were documented as ‘2 new rib fractures’.

Interviews with facility staff, hospital staff, and collateral agencies confirmed that whereas nursing staff were overseeing R1’s care immediately after the fall, they were unable to assess whether R1 had any internal injuries that were not assessable via a neurological assessment. Interviews and surveillance footage confirmed that R1 fell headfirst; R1 could have suffered a brain bleed or other injuries unbeknownst to staff. If R1 hadn’t ripped out their steri-strips the morning after the fall, the facility may not have taken R1 to the hospital, and the facility would have been unaware of R1’s additional injuries. Based on the information obtained during the investigation, there is sufficient evidence to support the claim that facility did not seek medical attention for R1 in a timely manner. This allegation is deemed Substantiated at this time.

A Civil Penalty in the amount of $500 was assessed during today's visit.

The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report was provided via email for signature, along with appeal rights.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20210721162508
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
02/18/2022
Section Cited
CCR
87468.2(a)(4)
1
2
3
4
5
6
7
87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following....: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
1
2
3
4
5
6
7
The Administrator agreed to do the following:
1. Submit a Plan of Action, detailing how staff are trained to respond to resident falls (witnessed and unwitnessed). In addition, detail the facility's protocol surrounding fall prevention. Submit protocol to CCL no later than 2/18/2022.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:
Based on the investigation, licensee did not comply with the section cited above, as staff were distracted and did not provide adequate supervision, resulting in R1 falling and sustaining injuries, which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
2. Review the protocol with all nursing staff. Submit the sign-in sheet and all applicable documents to CCLD no later than 2/25/2022.

A civil penalty in the amount of $500 is assessed.
Request Denied
Type A
02/18/2022
Section Cited
CCR
87465(g)
1
2
3
4
5
6
7
87465(g) Incidental Medical and Dental Care. 9-1-1 shall be telephoned immediately if an injury or other circumstance has resulted in an imminent threat to a resident’s health, including an apparent life-threatening medical crisis.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Administrator agreed to do the following:
1. Submit a Statement of Understanding, explaining the steps the facility will follow to avoid similar issues from happening again and to ensure compliance to Title 22 Regulations regarding emergency medical assistance.
8
9
10
11
12
13
14
Based on the investigation, the licensee did not comply with the section cited above, as the facility failed to ensure that R1 received timely medical attention following R1's fall which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/21/2021 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20210721162508

FACILITY NAME:SILVERADO THOUSAND OAKS, LLCFACILITY NUMBER:
565850072
ADMINISTRATOR:WILKIN, RONDAFACILITY TYPE:
740
ADDRESS:980 WARWICK AVETELEPHONE:
(805) 307-7300
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:82CENSUS: 42DATE:
02/16/2022
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Ronda WilkinTIME COMPLETED:
12:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident was left in soiled clothing.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Ashley Smith conducted a subsequent complaint visit to the facility today. The LPA met with Executive Ronda Wilkin and explained the reason for the visit.

On 07/21/2021, the Department received a complaint, alleging that Resident #1 suffered a fall, yet was not taken to the hospital until the next day. Once hospitalized, R1 was found to have sustained several injuries, which included several rib fractures. Community Care Licensing Division’s Investigations Branch (IB) Investigator Dennis Seng was assigned to the case. On 07/23/2021, the LPA interviewed the Executive Director and requested documents. Investigator Deng reviewed medical records on 8/24/2021; reviewed police records on 8/23/2021; interviewed hospital staff on 9/14/2021; interviewed three staff and three residents on 9/17/2021; interviewed R1’s family member on 9/17/2021; interviewed staff from a collateral agency on 9/17/2021, 9/20/2021, and 9/21/2021; interviewed three former staff members on 10/14/2021; and, reviewed facility surveillance video. During today's visit, the LPA interviewed staff from 9:55 a.m. - 11:30 a.m.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20210721162508
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/16/2022
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
26
27
28
29
30
31
32
Regarding the allegation: Resident was left in soiled clothing
It was alleged that R1's incontient needs were not met, resulting in staff leaving R1 in soiled clothing. The investigation revealed that on the evening that R1 suffered a fall, R1 was accompanied by a caregiver from an outside agency. One caregiver worked with R1 from 9:00 p.m. and left on 7/17/2021 at 6:00 a.m., and the other caregiver came on shift to work with R1 on 7/17/2021 at approximately 7:55 a.m. In addition to the caregiver assigned to work with R1 through the night, R1 was regularly checked throughout the night by facility nursing staff. Interviews revealed that from the hours of 6:00 a.m. to 8:00 a.m., facility staff were responsible for tending to R1’s care needs. Records review indicated that R1 was checked by facility staff at 7:30 a.m., and R1 did not appear distressed, unwell, or soaked in urine. Records review and interviews indicate that R1 pulled out their steri-strips between 7:30 a.m. – 8:00 a.m., to which at that point, R1 was sent to the hospital.

Staff interviews revealed that residents are checked on at least every two hours to ensure that incontinent needs are met timely. Staff agreed that at times, some residents refuse to be changed, but they try multiple intervention methods to ensure that resident needs are tended to in a timely manner. Interviews revealed that staff are responsive in meeting the toileting needs of the residents and are communicative with one another if they need assistance with changing or refreshing a resident. Lastly, interviews revealed that residents are regularly checked for skin breakdown or the presence of wounds, which none of the residents have at the time of this visit. Based on the information obtained, there is insufficient evidence to support the claim that due to lack of care and supervision, R1 was left in soiled clothing. R1 was checked within the two hour window prior to being hospitalized. Despite being checked and refreshed within a two hour time frame, R1 - or any resident - can soil their clothing soon after being checked. This allegation is deemed Unsubstantiated at this time.

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

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6