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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850072
Report Date: 05/15/2023
Date Signed: 05/15/2023 02:29:46 PM


Document Has Been Signed on 05/15/2023 02:29 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, LLCFACILITY NUMBER:
565850072
ADMINISTRATOR:STEPHANIE FUNDERBURGFACILITY TYPE:
740
ADDRESS:980 WARWICK AVETELEPHONE:
(805) 307-7300
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:82CENSUS: 54DATE:
05/15/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Stephanie FunderburgTIME COMPLETED:
02:40 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 Executive Director Stephanie Funderburg and explained the reason for the visit. The last visit was conducted 2/6/2023.

A file review of five (5) resident files was conducted from 9:45 a.m. – 11:15 a.m. Five files were reviewed for, but not limited to: admissions agreements, medical assessment, updated appraisals, consent forms. Out of the five files review, one out of five resident records (Resident #1 – R1) was missing a signed admissions/residency agreement. Technical violation issued, as parts of the residency agreement were observed in the file. Otherwise, resident records were in order.

A medication review for five residents was conducted from 11:30 a.m. – 2 p.m. The following was noted:
- R1 had an as-needed medication (Acetaminophen 650mg) that was administered one (1) time; however, staff did not document that R1 was assisted with this PRN medication as required per regulation.
- Resident #2 (R2) had an as-needed medication (Anti-Diarrhea 2mg) that was administered two (2) times since 3/11/2023; however, staff did not document that R2 was assisted with this PRN medication as required per regulation.
- Resident #3 (R3) had an as-needed medication (Acetaminophen 650mg (2 tabs – 325mg) that was administered one (1) time since 3/23/2023; however, staff did not document that R3 was assisted with this PRN medication as required per regulation.

The following deficiencies were observed (See LIC 809-D.) and cited from the CA Code of Regulations, Title 22.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: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2023
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 05/15/2023 02:29 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: 05/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/18/2023
Section Cited
CCR
87465(d)(3)

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87465(d)(3) Incidental Medical and Dental Care. The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.
This requirement is not met as evidenced by
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The Administrator agreed to do the following:
1. Host an in-service training, discussing topics that include but are not limited to: assisting residents with the self-administration of as-needed (PRN) medication
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Based on medication review, the licensee did not comply in the section cited above for three out of five (R1, R2, R3) residents as it pertains to documentation for assisting residents with the self-administration of PRN medication, which poses an immediate health and safety risk to residents in care.
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2. In-service must include nurses and medication technicians. Submit initial sign-in sheet by 5/18/2023. Training for all must be completed by 5/24/2023.

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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: 05/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2023
LIC809 (FAS) - (06/04)
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