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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850072
Report Date: 09/14/2022
Date Signed: 09/14/2022 11:19:31 AM

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
04/04/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20220404125919
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: 55DATE:
09/14/2022
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Ronda WilkinTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff failed to report the change of condition to R1's responsible party
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a subsequent visit. The LPA met with Executive Director Ronda Wilkin and explained the reason for the visit.

During the initial visit conducted on 4/8/2022, the LPA interviewed staff from 10:10 a.m. - 2:15 p.m., conducted a file review, obtained documents, and observed Resident #1 (R1) participating in a facility activity. On 09/07/2022, the LPA obtained documents and interviewed staff at 10:05 a.m., 10:35 a.m., and 10:47 a.m., and 12:10 p.m. In addition, an interview with R1’s representative took place on 9/8/2022 at 2:25 p.m. Today, the LPA interviewed R1 at 10:23 a.m.

Regarding the allegation: Staff failed to report the change of condition to R1's responsible party
It was alleged that R1’s responsible party was unaware of R1’s behavior of refusing medications. Inconsistent statements were provided; staff claimed that R1’s responsible party was aware of this behavior prior to R1 moving into the facility and identified this as a challenge for R1.
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: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
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-20220404125919
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: 09/14/2022
NARRATIVE
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Yet varying statements were provided from staff whether R1's responsible party was notified of R1's regular refusal of medications. A review of R1’s Electronic Medication Administration Record (eMAR) for the months of April-August 2021 indicated that R1 regularly refused to take medications. Staff interviews revealed that R1 was adamant in their refusal despite the different interventions staff attempted in assisting R1 with the self-administration of medication. As a result, staff said that R1’s medications were discontinued in August 2021. The LPA reviewed an order signed by R1’s physician on 8/28/2021, indicating that R1’s medications were discontinued, with the note pt refusing anyway. Progress notes did not indicate that R1’s responsible party was notified of R1’s ongoing medication refusal prior to discontinuing R1's medications. The LPA was unable to identify a facility service plan that indicated that R1 was not taking any medications, nor that it was discussed with R1’s responsible party.

R1’s responsible party said if they had known R1 was refusing their medications, they would have intervened. While staff claimed that the facility’s physician had a phone conversation with R1’s responsible party on 8/28/2021 regarding the decision to discontinue R1’s medications, R1’s responsible party denied claims of receiving a call or voice message from the physician. There was no documentation to support claims that R1’s responsible party was either notified or consulted regarding the decision to discontinue R1’s medications. R1’s responsible party said they were only made aware of R1’s status of not taking medications when R1 was hospitalized in April 2022. It was then that the hospital staff communicated to R1's responsible party that R1 allegedly was not taking medications, per feedback received from the facility.

Based on the information obtained during the course of the investigation, there is sufficient evidence to support the claim that staff failed to notify R1’s responsible party of the change of condition. Staff said R1 had regularly refused medications upon admission to the facility and believed that R1’s responsible party was aware of this behavior. However, there is no supporting documentation to aid in claims that R1’s responsible party was notified of R1’s refusals or of the discontinuation of all medications in August 2021. In addition, R1’s responsible party denied claims that they were ever notified of the ongoing refusals, as they would have intervened if they were aware of its regular occurrence. 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 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: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20220404125919
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: 09/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2022
Section Cited
CCR
87466
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87466 Observation of the Resident. ... When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the ... resident's responsible person, if any.
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The Administrator agreed to do the following:
1. Submit a Statement of Understanding, indicating how the faciilty will maintain voluntary compliance with regulation 87466. Submit statement to CCL no later than 9/16/2022.
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This requirement is not met as evidenced by:
Based on interview and record review, the licensee did not comply with the section cited above, as R1's responsible party was not notified of R1's refusal of medications, which poses an immediate health and safety risk to 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: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
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
04/04/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20220404125919

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: 55DATE:
09/14/2022
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Ronda WilkinTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff failed to assist resident with the self-administration of medication as prescribed
Staff failed to safeguard resident's personal property
Staff failed to meet resident's hygiene needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a subsequent visit. The LPA met with Executive Director Ronda Wilkin and explained the reason for the visit.

During the 4/8/2022 visit, the LPA interviewed staff from 10:10 a.m. - 2:15 p.m., conducted a file review, obtained records, and observed Resident #1 (R1) participating in an activity. On 09/07/2022, the LPA obtained records and interviewed staff at 10:05 a.m., 10:35 a.m., 10:47 a.m., and 12:10 p.m. In addition, an interview with R1’s representative took place on 9/8/2022 at 2:25 p.m. Today, the LPA interviewed R1 at 10:23 a.m.

Regarding the allegation: Staff failed to assist resident with the self-administration of medication as prescribed
It was alleged that staff failed to assist R1 with the self-administration of medication. A review of facility notes revealed that R1 was inconsistent with their medication regimen and would refuse to take their medications. A review of R1’s Electronic Medication Administration Record (eMAR) for the months of April-August 2021 indicated that R1 regularly refused to take medications.
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: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
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-20220404125919
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: 09/14/2022
NARRATIVE
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An order was signed by R1’s physician on 8/28/2021, indicating that R1’s medications were discontinued.

Interviews claimed that R1 was adamant in their refusal to take medications, regardless of the multiple interventions staff implemented. In speaking with R1, R1 claimed that they did not take any medications. The LPA spoke with R1, whom stated that they did not take medications because they did not need them. In addition, after R1 returned to the facility after being hospitalized on 4/3/2022, R1 was discharged with medications. However, R1 allegedly continued to be inconsistent with their medication regime. It was then discussed that R1’s medications be discontinued. An email dated 4/20/2022 confirmed that this was discussed with R1’s responsible party and physician, in which all parties were in agreement to discontinue the medications at that time. R1’s responsible party responded on 4/21/2022 and agreed with the joint decision to discontinue R1’s medications.

Based on the information obtained, there is insufficient evidence to support the claim that staff failed to assist R1 with the self-administration of medication. This allegation is deemed Unsubstantiated at this time.


Regarding the allegation: Staff failed to safeguard resident's personal property
It was alleged that the facility lost R1’s hearing aids. Interviews claimed that R1 would oftentimes remove their hearing aids, and at times, the facility would keep the hearing aids in the medication room to ensure that they were not lost or misplaced. The initial interview with the Executive Director revealed that at the time of the interview, R1’s hearing aids had gone missing, and that the facility had attempted to look for them. It was alleged that R1 had a tendency to ‘hide’ things in their room and that staff had to search for them to identify them. Whereas the hearing aids were found, the hearing aids were not listed or added to R1’s personal inventory list. Staff interviews claimed that R1 did not like to wear their hearing aids and when they did wear them, R1 would take them out. As a result, R1’s hearing aids were kept in the Wellness Center. During the 9/7/2022 visit, the LPA observed the hearing aids in question. The hearing aids were observed in their personal case, with R1’s name on the box. It appeared to be a pair of hearing aids that were ordered in 2014. Staff state that they try to have R1 wear them, but R1 refuses them. Staff stated that the hearing aids are stored in the Wellness Center to ensure that they are not misplaced.

Based on the information obtained, there is insufficient evidence to support the claim that the staff failed to safeguard R1’s hearing aids. This allegation is deemed Unsubstantiated at this time.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 29-AS-20220404125919
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: 09/14/2022
NARRATIVE
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Regarding the allegation: Staff failed to meet resident's hygiene needs
It was alleged that R1 was found with feces in their nails. Staff interviews claimed that R1 received minimal assistance with hygiene and only needed reminders. Staff stated that R1 would oftentimes refuse assistance with showers and claimed that R1 would shower on their own. Staff said that to assist R1, they will provide reminders, do a ‘change of face’ to have another caregiver assist them with a shower. Nonetheless, staff stated that R1 was always observed to be clean and denied claims of seeing R1 unkempt or with feces in their nails. Staff said that oftentimes, to get R1 to groom their nails, they will take them to the ‘salon’ to ensure that R1’s nails are properly cleaned. Otherwise, if R1’s nails appeared unkempt, staff will assist R1 with cleaning them or encourage R1 to do so if R1 refuses assistance. R1 currently has a regular manicure appointment within the facility. However, staff denied claims that they had ever observed R1’s nails with feces. The LPA observed R1's nails during today's visit at 10:23 a.m., and R1's nails were clean and R1's overall appearance was well maintained.

Based on the information obtained, there is insufficient evidence to support the claim that staff failed to meet R1’s hygiene needs. 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: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6