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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850072
Report Date: 08/03/2022
Date Signed: 08/03/2022 11:36:10 AM

Unsubstantiated


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
03/29/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-NP-20220329162507
FACILITY NAME:SILVERADO THOUSAND OAKS, LLCFACILITY NUMBER:
565850072
ADMINISTRATOR:WILKIN, RONDAFACILITY TYPE:
740
ADDRESS:980 WARWICK AVETELEPHONE:
(805) 307-7300
CITY:THOUSAND OAKSSTATE: ZIP CODE:
91360
CAPACITY:82CENSUS: 49DATE:
08/03/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ronda WilkinTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Due to lack of supervision, resident attained unsecured medications, resulting in hospitalization
Questionable Death
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to issue findings for the above allegations. The LPA met with Executive Director Ronda Wilkin and explained the reason for the visit.

On 3/29/2022, the Department received a complaint which alleged that Resident #1 (R1) obtained unsecured medications and as a result, was subsequently hospitalized. Allegedly, due to the ingestion of unsecured medications, R1 passed away. It was also alleged that the licensee failed to fulfill reporting requirements.

On 03/30/2022, the LPA interviewed seven staff members from 12:40 p.m. - 3:00 p.m., conducted a file review, and obtained documents. Additional staff interviews were conducted on 04/10/2022 at 11:24 a.m., 12:00 p.m., 1:05 p.m., and 1:39 p.m. In addition, an interview was conducted with a family member for Resident #1 (R1) on 8/1/2022 at 9:38 a.m. Hospice and hospital records were obtained and reviewed.
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: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
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-NP-20220329162507
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: 08/03/2022
NARRATIVE
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Regarding the allegation: Due to lack of supervision, resident attained unsecured medications, resulting in hospitalization
It was alleged that Resident #1 (R1) attained and ingested unsecured medications, resulting in hospitalization. A review of hospital records from September 2021 – December 2021 did not reveal instances where R1 was admitted to the hospital due to a medication error. A review of hospital notes revealed that R1 was admitted to the hospital for the following reasons: on 9/15/2021 due to a fall and associated pain as a result of the fall; on 9/16/2021 due to a fall due to increased weakness; on 11/07/2021 due to a choking incident in which R1 was placed on aspiration precautions thereafter and diagnosed with aspiration pneumonia; on 11/15/2021 due to a fall and lacerations; on 12/12/2021 due to a fall, and on 12/22/2021 due to slurred speech and a fall. On 12/22/2021, R1 was also noted to have had a stroke. R1 thereafter was admitted to hospice on
12/23/2021.

Interviews with staff and a review of submitted incident reports did not validate claims that a medication cart was left unlocked. Staff denied claims that R1, or any resident for that matter, gained access to unsecured medications. In addition, an interview with a family member for R1 denied claims that such an incident took place. As previously stated, a review of hospital records did not indicate that R1 ingested medications which aided in the reason for hospitalization. A review of hospice notes did not document an incident in which R1 had to be evaluated due to a possible medication error. Staff interviews revealed that R1 was very complaint with their medication regime but denied claims that there was ever a medication error while assisting R1 with the self-administration of medication.

Based on the investigation, there is insufficient evidence to support the claim that due to lack of supervision, resident attained unsecured medications, resulting in hospitalization. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Questionable Death
It was alleged that R1 was hospitalized due to ingesting unsecured medications, which resulted in R1’s death. A review of hospital records from September 2021 – December 2021 did not reveal instances where R1 was admitted to the hospital due to a medication error. An interview with R1’s family member noted that prior to being admitted to the facility in August 2021, R1 would often call 9-1-1 due to perceived breathing issues and was highly concerned for their health.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-NP-20220329162507
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: 08/03/2022
NARRATIVE
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On 9/15/2021, R1 was hospitalized due to a fall and associated pain as a result of the fall. On 9/16/2021, R1 was hospitalized for a fall which was due to increased weakness. On 11/07/2021, R1 was hospitalized due to a choking incident in which R1 was placed on aspiration precautions and was diagnosed with aspiration pneumonia. On 11/15/2021, R1 suffered another fall and was hospitalized with lacerations. On 12/12/2021, R1 suffered a fall and was diagnosed with a brain bleed. Lastly, on 12/22/2021, R1 was hospitalized because of slurred speech and increased confusion. On 12/22/2021, R1 was also noted to have had a stroke.

Due to R1’s change of condition and subsequent hospitalization on 12/22/2021, R1 was admitted to hospice on 12/23/2021 with the diagnoses of CVA and vascular dementia. CVA, otherwise known as a cerebrovascular accident, is medically known as a stroke. The Hospice Care Plan dated 12/23/2021 documented that R1 had ‘multiple TIA’, which according to Mayo Clinic, is medically known as transient ischemic attacks, which have symptoms to those of a stroke. Common symptoms include weakness, numbness or paralysis in the face or parts of the body, slurred or garbled speech, and/or loss of balance or coordination.

Hospice records indicated that R1 received visits on 12/23/2021, 12/24/2021, 12/25/2021, 12/27/2021, 12/29/2021, 12/30/2021, and 12/31/2021. A review of notes indicated that R1 suffered a fall on 12/24/2021 and 12/25/2021 as a result of increased weakness. R1 was observed with excessive secretions and a cough on 12/27/2021. On 12/29/2021, R1 was visited twice by hospice, as R1 experienced shortness of breath and a drop in blood pressure. This change of condition continued through 12/30/2021 and on 12/31/2021, R1 passed away at the facility. The death certificate indicated that the cause of death was a cerebrovascular accident and vascular dementia. A cerebrovascular accident (CVA) is also referred to as a stroke or a brain attack, which is an interruption in the flow of blood cells to the brain. R1’s family member noted that they believed R1 had experienced multiple TIAs in the years prior to their passing, unbeknownst to R1.

Based on the investigation, there is insufficient evidence to support the claim that the cause of R1’s death was due to the ingesting of medications and a subsequent hospitalization, which resulted in a death. R1 was often hospitalized either due to a fall or at R1’s request due to a perceived change of condition. Whereas there is evidence that R1 suffered several strokes, subpoenaed hospital records did not indicate that R1 was hospitalized due to a medication error, nor is there sufficient evidence per the interviews conducted with staff and R1’s family to confirm the correlation between a stroke and ingested medications. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited. 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: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC9099 (FAS) - (06/04)
Page: 3 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
03/29/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-NP-20220329162507

FACILITY NAME:SILVERADO THOUSAND OAKS, LLCFACILITY NUMBER:
565850072
ADMINISTRATOR:WILKIN, RONDAFACILITY TYPE:
740
ADDRESS:980 WARWICK AVETELEPHONE:
(805) 307-7300
CITY:THOUSAND OAKSSTATE: ZIP CODE:
91360
CAPACITY:82CENSUS: 49DATE:
08/03/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ronda WilkinTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Licensee failed to comply with reporting requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to issue findings for the above allegations. The LPA met with Executive Director Ronda Wilkin and explained the reason for the visit.

On 3/29/2022, the Department received a complaint which alleged that Resident #1 (R1) obtained unsecured medications and as a result, was subsequently hospitalized. Allegedly, due to the ingestion of unsecured medications, R1 passed away. It was also alleged that the licensee failed to fulfill reporting requirements.

On 03/30/2022, the LPA interviewed seven staff members from 12:40 p.m. - 3:00 p.m., conducted a file review, and obtained documents. Additional staff interviews were conducted on 04/10/2022 at 11:24 a.m., 12:00 p.m., 1:05 p.m., and 1:39 p.m. In addition, an interview was conducted with a family member for Resident #1 (R1) on 8/1/2022 at 9:38 a.m. Hospice and hospital records were obtained and reviewed.
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: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
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-NP-20220329162507
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: 08/03/2022
NARRATIVE
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Regarding the allegation: Licensee failed to comply with reporting requirements

It was alleged that the licensee failed to submit incident reports pertaining to R1. A review of internal records and emails revealed that the licensee submitted incident reports for R1’s hospitalization for 12/12/2021 and R1’s passing on 12/31/2021, but the licensee did not submit incident reports for R1’s hospitalizations from 9/16/2021, R1’s choking incident and subsequent hospitalization on 11/07/2021, nor R1’s stroke and subsequent hospitalization from 12/22/2021. Based on the information obtained, there is sufficient evidence to support the claim that the licensee failed to comply with reporting requirements. This allegation is deemed Substantiated at this time.

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 and appeal rights were provided.

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

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-NP-20220329162507
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: 08/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/08/2022
Section Cited
CCR
87211(a)(1)(D)
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87211(a)(1)(D) Reporting Requirements. A written report shall be submitted … within seven days of the occurrence of any of the events specified ... (D) Any incident which threatens the welfare, safety or health of any resident ...
This requirement is not met as evidenced by:
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The licensee has agreed to do the following:
1. Submit incident reports for R1’s incidents and/or hospitalizations for the record. Review the report for exact dates. Submit to CCL no later than 8/8/2022.
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Based on record review, the licensee did not comply with the section cited above, as reports were not submitted for all of R1’s hospitalizations, which poses a potential health and safety risk for residents in care.
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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: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6