565850072-2-6-2023-29-AS-ASMH-CNSRP3-20230206121116

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850072
Report Date: 02/06/2023
Date Signed: 02/06/2023 12:12:18 PM

Document Has Been Signed on 02/06/2023 12:12 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:	STEPHANIE FUNDERBURG		FACILITY TYPE:	740
ADDRESS:	980 WARWICK AVE		TELEPHONE:	(805) 307-7300
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	82	CENSUS: 48	DATE:	02/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Stephanie Funderburg		TIME COMPLETED:	12:20 PM

NARRATIVE

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Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced required annual visit. Along with the annual visit, the purpose of today’s visit was to ensure the facility was maintaining substantial compliance as discussed in the Non-Compliance Conference that took place on 10/26/2022. As a result of the non-compliance conference, the licensee is placed on frequent monitoring for a period of two years. The LPA met with staff and explained the reason for the visit.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Dining room furniture on both floors appeared to be in good condition.

BEDROOMS: The LPA observed a randomly selection of resident rooms, and rooms were furnished appropriately with clean linens, furnishings and sufficient lighting.

RESTROOMS: Restrooms were stocked with soap and paper towels. Water temperature was tested on the first and second floor, and temperature ranged from 105.3– 107.7 degrees Fahrenheit. Hand washing signs promoting good hand hygiene were observed in the common restrooms.

COMMON SPACES: Upon entry to the facility, the Bistro area was unclean, as chips and trash was observed scattered on the grounds. At 9:10 a.m., the LPA observed a pile of empty water bottles and a soda can in the outdoor courtyard. At 9:15 a.m., the LPA observed trash (open cracker wrappers, ice cream) scattered on the counter in the upstairs kitchen/bistro area. At 9:16 a.m., an unknown substance was observed melted in the cabinet. In addition, there was a hat and sock in the cabinet of the 2nd floor kitchen/bistro area. At 9:20 a.m., the couch cushions on the 2nd floor balcony were observed to be unclean.

The LPA walked through the facility at 11:21 a.m. The common space at the Bistro near the front entrance was clean and residents were occupying the kitchen/bistro area on the 2nd floor, yet the counters appeared to be clear. The empty water bottles observed in the downstairs courtyard were still present at 11:32 a.m.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

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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Document Has Been Signed on 02/06/2023 12:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(2)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in three (3) out of seven (7) staff (S1, S2, S3) whom had fingerprint clearance but were not associated to this location, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 02/06/2023
	Plan of Correction
1 2 3 4	The Administrator agreed to do the following: 1. Ensure S1, S2, and S3 are associated to this location by the end of the day.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/06/2023 12:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as there was trash observed in the first and second floor bistro and downstairs courtyard, and cushions on the second floor balcony were unclean, which poses a potential health and safety risk to persons in care.
	POC Due Date: 02/13/2023
	Plan of Correction
1 2 3 4	The Administrator agreed to do the following: 1. Review protocol for staff as it pertains to facility cleanliness. Submit sign in sheet to CCL no later than 2/13/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/06/2023

NARRATIVE

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The LPA tested the delayed egress doors and doors were operable during the visit.

EXTERIOR: The facility has several enclosed courtyards with appropriate outdoor seating for resident use. There were no bodies of water observed during today’s visit.

FILES: The LPA reviewed a selection of staff files. Out of the seven (7) files reviewed, the LPA identified three (3) persons that were fingerprint cleared, but not associated to this location (Staff #1, Staff #2, Staff #3). Records indicate the staff have worked at the facility in excess of five days. This is an immediate civil penalty and civil penalties will be assessed in the amount of $100 per day for five days ($100 x 5 days) for S1, S2, and S3.

INFECTION CONTROL: Staff were observed wearing appropriate face coverings. The facility continues to screen visitors and staff upon entry into the facility. The facility has an adequate supply of Personal Protection Equipment (PPE). Hand sanitizer was available for staff, residents and visitors. The facility can designate a section of the facility for isolation and quarantine purposes if the facility has a confirmed case of COVID-19. The facility keeps record of staff and resident vaccinations.

The following deficiencies were observed (See LIC 809-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. Civil penalties assessed during today’s visit. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

LIC809 (FAS) - (06/04)

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