Silverado Thousand Oaks

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kelly Dulek initiated an unannounced Case Management – Incident visit for an incident that was self-reported via telephone on 08/18/2026. LPA met with Administrator Ashiman (Ashi) Gill and Director of Health Services Heather Hampel. Entrance interview conducted. The Woodland Hills Regional Office (RO) received an incident report via email on 08/16/2026 at 02:06PM. The LPA conducted a telephone call with the facility Administrator and Director of Health Services at 08:00AM on 08/18/2026. During the telephone conversation, Silverado managers informed the LPA that an elopement incident had occurred on Saturday 08/15/2026. In the incident Resident #1 (R1), who is a newer resident at the facility was observed walking out of the facility's front door. The front desk staff had opened the door and the resident walked out into the facility parking lot. The resident was observed walking towards the sidewalk and then down the sidewalk when the front desk staff alerted care staff what had occurred. Additional staff then responded and found R1 ambulating down the sidewalk outside the facility. During today's visit, LPA again discussed the incident with facility management. Management reported R1 did not sustain any injuries as a result of the elopement incident. R1 was outside the facility out of line of sight of facility staff for approximately thirty (30) seconds before R1 was redirected back into the facility safely. Following the incident, the staff involved was placed on administrative leave and their employment has since been terminated. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D). Exit interview conducted, appeal rights discussed, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 19, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Aug 21, 2026

87464 Basic services (f)(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section as R1, who has a diagnosis of dementia and is unable to leave the facility unassisted, exited the facility's front doors and was without supervision, which posed an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 19, 2026

Plan of correction: Administrator indicated the staff involved in the elopement incident is no longer employed at the facility, All staffare being retrained on elopement procedures and will be participating in elopement drills.Proof of staff training & elopement drills will be sent to CCLD by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kelly Dulek arrived on July 29, 2026 for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation. On May 31, 2024, the Department concluded a complaint investigation regarding the following allegations: “Physical Abuse - Resident #1 (R1) was physically and emotionally injured by Staff #1 (S1) while under the care and supervision of the facility” and “Conduct Inimical - Staff #1 (S1) was arrested and charged with misdemeanor elder abuse and being under the influence of a controlled substance”. The licensee was cited for California Code of Regulations (CCR) 87468.1(a)(3) Personal Rights of Residents in All Facilities and Health and Safety Code §1569.58(a)(2) Conduct Inimical. At the time of the complaint visit on May 31, 2024, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code §1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for physical abuse. The Welfare and Institutions Code Section 15610.63 for physical abuse means any of the following: (b) Battery, as defined in Section 242 of the Penal Code. Penal Code 242 defines battery as “any willful and unlawful use of force or violence upon the person of another.” This is evidenced by the facility surveillance video captured S1 willfully commit violence against R1 by dragging, taunting, slapping and air kicking R1 while under the care and supervision of the facility. As a result, R1 sustained a laceration to their arm. The staff denied that they committed the abuse – despite video evidence of the acts. Moreover, S1 admitted to smoking methamphetamine and a drug test confirmed that S1 had drugs in their system. The staff was arrested and charged with PC 368(b)(1) for Elderly Abuse and Health and Safety Code §11550(a) for Under Report Continued on LIC 809-C the Influence of a Controlled Substance. Today July 29, 2026, the Department will be issuing a civil penalty per Health and Safety Code §1569.49(f) for a violation that the Department determines resulted in Physical Abuse of a resident in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on May 31, 2024, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal Rights provided. Administrator Ashiman Gill and signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Jul 29, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kelly Dulek arrived on July 29, 2026 for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation. On March 25, 2025, the Department concluded a complaint investigation regarding the following allegations: Neglect/lack of care & supervision – Resident 1 (R1) caused severe injuries to Resident 2 (R2) that led to the death of R2; Facility did not provide basic services to resident(s) in care; Facility did not reappraise resident(s) in care; Facility retained a resident that required a higher level of care; Facility staffing is inadequate. The licensee was cited for California Code of Regulations (CCR) 87464(f)(2) Basic Services, CCR 87463(a) Reappraisals, and CCR 87411(a) Personnel Requirements - General. At the time of the complaint visit on March 25, 2025, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(e). The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that the Department determines resulted in the death of a resident. This is evidenced by the facility not providing proper care and supervision which led to a resident #1 (R1) physically attacking resident #2 (R2) while in their shared room, which ultimately led to the death of R2. Today July 29, 2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(e) Report Continued on LIC 809-C for a violation that the Department determines resulted in the death of a resident in the amount of $15,000. However, since an immediate civil penalty of $500 was previously issued on March 25, 2025, the amount of the civil penalty issued today will be $14,500. Exit interview conducted. A copy of the report issued. Appeal Rights provided. Administrator Ashiman Gill and signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Jul 29, 2026

Allegation investigated: Facility is not sufficiently staffed to meet the needs of residents in care Resident sustained multiple falls due to staff neglect Facility staff did not adequately address resident's fall risk resulting in injuries. Staff did not notify authorized representative of incident Staff did not address a resident's change in medical condition in a timely manner Staff do not treat residents with dignity and respect

Licensing Program Analyst (LPA) Kelly Dulek and Investigations Branch (IB) Investigator Trainee Amina Luckett conducted an initial complaint investigation regarding the above allegations. LPA and Investigator Trainee met with Administrator Ashiman (Ashi) Gill and explained the reason for the visit. During today's visit, LPA and Investigator Trainee interviewed Administrator at 09:51AM, toured the facility with Administrator at 10:11AM, interviewed six (6) staff in person and two (2) staff telephonically from 10:36AM to 01:30PM, observed Resident #1 (R1) and interviewed R1's family members at 01:43PM. LPA also reviewed and obtained copies of relevant documents. The following was then determined: Report Continued on LIC 9099-C (p.2) Unsubstantiated Continued from LIC 9099 (p. 1) Allegation: "Facility is not sufficiently staffed to meet the needs of residents in care:" The complaint alleges that there are not enough staff working in the facility to meet resident needs. Staff schedules were reviewed for the past month. Review of staff schedules revealed that there are five (5) care staff plus two (2) charge nurses on shift during the 06:00AM - 02:30PM shift. There are four (4) care staff plus two (2) charge nurses scheduled during the 02:00PM to 10:30PM shift. On the overnight shift, there are two (2) care staff and one (1) charge nurse scheduled. In addition, there are activity staff present daily, as well as management staff to assist during the day and evening hours. Interviews with staff revealed the current schedule is sufficient to meet the needs of residents in care. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Allegations: "Resident sustained multiple falls due to staff neglect" and "Facility staff did not adequately address resident's fall risk resulting in injuries:" Interviews revealed that during the overnight shift that ended on 06/12/2026, R1 had awoken during the night. R1 attempted to get out of their bed and had slid to the floor four (4) times. R1 does have a bed alarm, so each time staff responded to R1's room to assist them. Interviews revealed that all residents are regularly observed every two (2) hours during the overnight shift. In the early morning hours of 06/12/2026, staff responded to R1's room every hour when R1 was getting out of bed. Additionally, R1 does have a landing mat next to their bed and R1's family provided R1 a lower bed to mitigate a potential fall risk. Interviews and documents reviewed revealed R1 has not fallen from a standing position while residing at the facility, but typically slides down to the floor when they attempt to get out of bed. Although R1 did hit their head on the wall at approximately 04:20AM on 06/12/2026, staff was present in R1's room at that time and was a result of a behavior, not a fall. Responding emergency personnel indicated "[patient] was assessed, no injuries found." R1 has not sustained any injuries observed when getting out of bed unassisted. Staff indicated that when R1 ambulates about the facility using their walker, staff do walk with R1 to ensure their safety. The information obtained during the investigation did not include evidence sufficient to corroborate the Report Continued on LIC 9099-C (p.3) Continued from LIC 9099-C (p. 2) allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Allegation: "Staff did not notify authorized representative of incident:" On the morning of 06/12/2026, when R1 slid off their bed, it was alleged that staff did not notify R1's responsible person timely. Interviews revealed that R1 slid off their bed at approximately 04:20AM and staff did call 9-1-1 as R1 had been observed hitting their head on the wall as a behavioral expression once R1 was on the floor. The charge nurse called emergency services and tended to the resident's needs. Emergency services responded to the facility at 04:30AM and charge nurse began talking to emergency personnel to inform them of R1's status. At that time, one of the emergency personnel called R1's authorized representative and informed them of the incident. According to R1's family member, within ten (10) minutes, R1's family member talked to the facility charge nurse over the phone related to the incident. R1's family member felt the time frame was sufficient and denied the allegation. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Allegation: "Staff did not address a resident's change in medical condition in a timely manner:" The complaint alleges that at the time of the incident, R1 had a change in condition, which was not addressed. Records reviewed revealed R1 had been tested for a urinary tract infection (UTI) on 06/11/2026, which resulted in a positive diagnosis. Facility staff had notified R1's physician and requested orders for antibiotics. Additionally, Director of Health Services also sent a request to R1's primary care physician to review R1's prescribed medication for potential changes. This request was sent on 06/12/2026 at 08:47AM, just after R1 had slipped out of their bed. Additionally, interviews revealed facility staff have been in regular communication with R1 and their responsible party related to changes with R1 and their care needs. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Report Continued on LIC 9099-C (p. 4) Continued from LIC 9099-C (p. 3) Allegation: "Staff do not treat residents with dignity and respect:" LPA and Investigator Trainee interviewed staff and family members related to this allegation. No staff interviewed reported ever observing any other staff not treating residents with respect. Additionally, no staff or management interviewed reported hearing any reports related to treating residents disrespectfully. Family members interviewed indicated they have no concerns with the staff or their interactions with the residents in care. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. No deficiencies cited during today's visit. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 16, 2026 · control 29-AS-20260612160441

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kelly Dulek conducted a Case Management - Incident visit regarding a self-reported incident. LPA met with Administrator Ashiman (Ashi) Gill and Director of Health Services Heather Hampel and explained the reason for the visit. On 05/04/2026, LPA Dulek received a telephone call from the management team indicating that during a care conference that day, a family member reported an alleged incident involving Resident #1 (R1) and Staff #1 (S1). An incident report and suspected abuse report was submitted to the Woodland Hills Regional Office (RO) on 05/05/2026. Incident Report indicated R1 reported to their family member that on 04/29/2026, S1 had put their finger inside R1 while S1 was assisting R1 with their shower. While R1 reported to their family member timely, R1's family member did not inform the facility until 05/04/2026. Immediately following knowledge of the alleged incident, facility management informed all relevant parties of the alleged incident and adjusted R1's care to include two (2) female staff during all personal care provided. Police responded to the facility, indicated there was no crime committed, and a written report was filed. The facility then conducted an internal investigation into the alleged incident. During LPA's visit today, LPA discussed the incident report with Administrator and Director of Health Services at 10:32AM, toured the facility with Administrator at 10:40AM, LPA observed and talked with R1, and LPA obtained copies of pertinent documents. No immediate health and safety hazards were identified during facility tour. Review of documents obtained and interview revealed at the time of the allegation, another staff, not S1 had been assisting R1 with their showers at that time and for approximately four (4) weeks prior to the alleged Report Continued on LIC 809-C incident. R1 has a history of hypersexual behaviors and recent increased incidence of hallucinations. It was also discovered that R1 had a urinary tract infection (UTI) at the time of the allegation. R1's medical and psychiatric team were consulted to discuss possible medication changes or adjustments, including antibiotics for the UTI. R1's service plan was also adjusted to reflect this change in condition and to add additional behavioral tracking. At this time, no citations were issued. If after reviewing all information further investigation is warranted, LPA may return at a later date. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, May 14, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Quoc Huynh and Kelly Dulek arrived unannounced at 09:40AM for a required one year visit. The LPAs initially met with Health Services Director Heather Hampel and explained the reason for the visit. Administrator joined shortly thereafter. Entrance interview conducted. Beginning at 11:09AM, the LPAs, along with Health Services Director toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: COMMON AREAS: The facility is a two-story building. On the first floor, there are the kitchen facilities, dining room, Bistro, laundry rooms, Wellness Center, fitness center, office spaces, and common restrooms. On the second floor, there is a beauty salon, spa, Wellness Center, second floor dining, a private dining room, several activity spaces, office spaces and common restrooms. The LPAs observed common areas to be clean and in good condition. There were no obstructions and/or tripping hazards throughout the facility. There were cameras in the common areas, outdoor courtyard, and exterior perimeter. Required postings were found in the hallway on the first floor. There are fire extinguishers throughout the facility, which were serviced 07/21/2025. Fire alarm system is tested annually with the last inspection on 06/16/2025. 5-year inspection was conducted on 08/11/2025. Both inspections were conducted by Nelson Fire Protection; all systems passed. RESIDENT ROOMS/RESTROOMS: The LPAs observed ten (10) randomly selected rooms on the first and second floor and no immediate health or safety hazards was observed. Restrooms were clean, with properly installed grab-bars in resident bathrooms and slip-resistant surfaces. Appropriate furniture was also observed Report Continued on LIC 809-C in the units. Water temperature was tested throughout the units and measured between 113.9 degrees F and 118.4 degrees F, which is within the required range. OUTDOOR AREAS: There are three (3) outdoor gated courtyards; two (2) are on the first floor and one (1) is on the 2nd floor. The LPAs observed outdoor furniture, with a covered shaded area for residents. There were no bodies of water observed during today’s visit. KITCHEN: The main kitchen is located on the 1st floor. Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. Facility uses Sysco Foods for food deliveries, and food delivery takes place twice a week. There was a sufficient supply of perishable and non-perishable food, as well as emergency food and water. Food appeared to be of good quality. RECORDS: Record review began at 11:55AM. The LPAs reviewed five (5) resident files for, but not limited to: admissions agreements, medical assessment, updated appraisals. Resident records reviewed were in order at this time. The LPAs reviewed personnel records, including but not limited to: job application, health assessments, TB results, criminal record statements and clearances, first aid/CPR certification. Staff files reviewed were in compliance with regulation at this time. MEDICATION: Medications review began at 02:34PM. The LPAs reviewed medications for four (4) residents. Medications are maintained locked inaccessible to residents in the Wellness Centers located on the first and second floor. Four (4) out of four (4) resident medications reviewed were documented and stored in compliance with regulation at this time. INFECTION CONTROL/EMERGENCY DISASTER: LPAs reviewed the facility's infection control plan and Emergency Disaster plan. LPAs noted that the facility is in compliance with regulation. Facility conducts emergency disaster drills as required with the last documented drill on 02/19/2026. INTERVIEWS: Three (3) residents and three (3) staff were interviewed. No concerns were noted. DOCUMENTS OBTAINED: LPAs gathered a copy of the facility's liability insurance, register of facility residents, Silverado physician's report, and personnel report. No deficiencies cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 25, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit at 10:30AM. The LPA met with Administrator Robloe (Rob) Babasanta and Director of Health Services Heather Hampel and explained the reason for the visit. Entrance interview conducted. The Department received a self-reported incident and a subsequent death report regarding Resident #1 (R1) on 09/15/2025. LPA requested documents for R1 be sent via email, which were received on 09/24/2025. Incident report indicates R1 was taking a walk with facility staff when R1 experienced chest pain and began to collapse. 9-1-1 was called and paramedics continued CPR, however R1 was pronounced deceased. During today’s visit, LPA conducted a brief physical plant tour to ensure there are no immediate health and safety concerns, conducted in-person interviews with Administrator and Director of Health Services and LPA obtained copies of pertinent documents relevant to the incident. Record review revealed R1 had a diagnosis of chronic atherosclerosis of aorta. Interview revealed about a week prior to the incident, R1 had visited the hospital and was medically clear to return to the facility. R1 had returned to regular activities and enjoyed taking walks multiple times a day. On the date of the incident, staff was with R1 when R1 collapsed, staff assisted R1 and began cardiopulmonary resuscitation (CPR.) Paramedics arrived and continued CPR, however, R1 was pronounced deceased. Following R1’s death, Administrator continued to communicate with R1’s family. Administrator provided LPA with email communication, which indicates R1’s cause of death was listed as “cardiac tamponade secondary to ruptured aortic aneurysm.” R1’s death was listed as natural. No citations issued. Should further investigation be warranted, LPA will return at a later date. Exit interview conducted. Report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, Oct 2, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kelly Dulek arrived on September 19, 2025 for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation. The LPA met with Director of Health Services Heather Hampel. On February 16, 2022, the Department concluded a complaint investigation regarding the following allegations: Due to lack of care and supervision, resident suffered a fall, resulting in injuries; and facility did not seek medical attention in a timely manner. The licensee was cited for California Code of Regulations (CCR) 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities; and 87465(g) Incidental Medical and Dental Care. At the time of the complaint visit on February 16, 2022, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code §1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility not providing proper care and supervision that resulted in the resident (R1) falling, sustaining rib fractures and hematomas, which required hospitalization. In addition, R1 did not receive timely medical attention until the day after the Report Continued on LIC 809-C incident. Today, September 19, 2025, the Department will be issuing a civil penalty per Health and Safety Code §1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on February 16, 2022, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Director of Health Services Heather Hampel and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Sep 19, 2025

Allegation investigated: Resident was hospitalized due to a urinary tract infection resulting from staff neglect Facility staff did not meet resident’s incontinence care needs Facility staff handled resident in a rough manner Facility staff did not ensure resident had sufficient intake of food Facility staff did not answer resident’s calls for assistance Facility staff yelled at resident Facility staff did not provide records to resident’s responsible person

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint visit to this facility to deliver findings. At 11:45AM, the LPA was greeted by front desk staff and LPA explained the reason for the visit. At 11:57AM, the Administrator Rob Babasanta met with the LPA. On 04/09/2024, A referral was made to Community Care Licensing Division's (CCLD) Investigation Branch (IB) and was accepted as an assignment to obtain medical records and home health records for Resident #1 (R1). During the initial visit conducted on 4/10/2024 between 10:04 a.m. and 12:15 p.m., LPA Teresa Camara conducted a physical plant tour, interviewed the Administrator and obtained pertinent documents. During a subsequent visit conducted on 03/25/2025, LPAs Peraldi, Dulek and Huynh conducted a physical plant tour and conducted interviews with the Administrator, six (6) staff and four (4) residents. The LPAs also requested and obtained copies of pertinent documents during the subsequent visit. Report Continued on LIC 9099-C Unsubstantiated Regarding allegation: 1.) Resident was hospitalized due to a urinary tract infection resulting from staff neglect. It was alleged that Resident #1 (R1) had three (3) urinary tract infections (UTIs) while residing at the facility, one of which resulted in a hospital stay in November 2023. Medical records from Los Robles Regional Medical Center were obtained for R1 and the following was noted: R1 was first observed at the hospital on 10/25/2023. R1 was admitted to the hospital on 10/26/2023 and was discharged back to the facility on 11/02/2023. R1’s condition throughout the hospitalization were listed in various medical documents as coffee ground emesis, shortness of breath, abdominal pain, chest pain and vomiting. During R1’s hospitalizations, R1 had an upper GI endoscopy procedure done. A physical and multiple tests were performed prior to the procedure, and no immediate complications were listed on the Endoscopy Report. Additionally, R1’s discharge records did not list UTI as a diagnosis. In R1’s home health visit notes dated 03/04/2024, a urinalysis was sent out for a possible, continued UTI. However, a UTI was not listed as a diagnosis. R1 was again hospitalized at Los Robles Regional Medical Center on 03/30/2024 for acute GIB, Sepsis, Asp PNA and Complicated UTI. R1 was discharged on 04/11/2024; however, R1 was already moved out of the facility and moved into another facility. R1 moved out of the facility on 03/24/2024. The information obtained during the investigation did not include evidence sufficient to corroborate the above allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Regarding allegation: 2.) Facility staff did not meet resident’s incontinence care needs. It was alleged R1 was found on multiple occasions sitting in feces and with feces around R1’s scrotum. Per record review, R1 was admitted to the facility on 08/22/2023. Per R1’s physician report dated 05/31/2023, R1 was not able to care for own toileting needs. LPA Peraldi reviewed R1’s home health visit report notes from 07/10/2023 through 03/25/2024 and the following was noted: there was no mention of R1 being found with soiled diapers or sitting in feces. Interview with the Administrator stated that since R1 was in a wheelchair, staff would check on R1 at least every 2 hours or as needed. The information obtained during the investigation did not include evidence sufficient to corroborate the above allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Regarding allegation: 3.) Facility staff handled resident in a rough manner. It was alleged that facility staff handled R1 in a rough manner resulting in bruising. The complainant did not state where bruises were on Report Continued on LIC 9099-C R1’s body or any other details. Interviews conducted with staff denied staff handing R1, or any resident, in a rough manner. R1’s medical records from Los Robles Regional Medical Center for R1’s hospitalizations on 10/25/2023 and 03/30/2024 did not note any bruising on R1’s body. The information obtained during the investigation did not include evidence sufficient to corroborate the above allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Regarding allegation: 4.) Facility staff did not ensure resident had sufficient intake of food. It was alleged that R1 was not being fed and the food being served to R1, R1 would not eat. Per record review, R1 was admitted to the facility on 08/22/2023. Per R1’s physician report dated 05/31/2023, R1 was to be on a diabetic diet. R1’s Preplacement appraisal dated 08/17/2023, noted R1’s special diet as diabetic. R1’s service plan, dated 09/06/2023, listed raw onion as R1’s allergy. LPA Peraldi reviewed R1’s home health visit report notes from 07/10/2023 through 03/25/2024 and the following was noted: R1’s home health notes mention R1’s appetite depends on what is being served to R1. On 07/10/2023 and 03/04/2024, it was noted that R1 had difficulty complying with any medical instructions (for example medications, diets, exercise) within the past 3 months. On 03/04/2024, it was noted that R1 rarely eats a complete meal and generally eats only about half of any food offered. It was noted that R1 also drinks protein shakes and dietary supplements to increase calories. Throughout R1’s home health notes R1 was also noted to have diminished cardiovascular capacity and generalized weakness which also attributed to R1’s lack of appetite. During the initial complaint visit and subsequent visits, the LPAs observed a sufficient supply of perishable and non-perishable food. Four (4) out of four (4) residents interviewed revealed that the food is good, adequate, and well portioned. The information obtained during the investigation did not include evidence sufficient to corroborate the above allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Regarding allegation: 5.) Facility staff did not answer resident’s calls for assistance. It was alleged that R1 would wait 30 minutes for facility staff to assist R1 when the call button was pressed. Interview with the Administrator revealed that R1 would press the call button but then a second later would press it again which turns off the call. The Administrator said that staff would remind R1 to only press the button once. The Administrator also explained that for residents who can’t use the call buttons, there are bed pads that have Report Continued on LIC 9099-C censors if a resident falls or has a sudden movement that alert staff. During the subsequent visit on 03/25/2025, at 11:08 a.m., the LPAs tested a call button and staff arrived within 2 minutes, thinking a resident pressed the button. Interviews with residents did not voice concerns regarding the wait time for assistance. The information obtained during the investigation did not include evidence sufficient to corroborate the above allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Regarding allegation: 6.) Facility staff yelled at resident. It was alleged that a facility staff that was described as a registered nurse (RN) was overheard yelling at R1. Interview with Administrator revealed that he has not heard or observed staff yelling at residents. Interviews with staff also denied staff yelling at residents, including R1. Interviews with residents did not voice any concerns regarding staff treatment. The information obtained during the investigation did not include evidence sufficient to corroborate the above allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Regarding allegation: 7.) Facility staff did not provide records to resident’s responsible person. It was alleged that facility staff refused to give R1’s responsible party R1’s medical records. Administrator stated that he did give R1’s responsible party hard copies of R1's records. The Administrator explained that when records are requested, he puts in a written request to Silverado’s home office. Once approved through the home office, the Administrator will then release the records. However, in the case of R1, the records were released to R1's family immediately upon request. The information obtained during the investigation did not include evidence sufficient to corroborate the above allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. No citations issued. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 30, 2025 · control 29-AS-20240409091302

Allegation investigated: Neglect/lack of care & supervision – Resident 1 (R1) caused severe injuries to Resident 2 (R2) that led to the death of R2 Facility did not provide basic services to resident(s) in care Facility did not reappraise resident(s) in care Facility retained a resident that required a higher level of care Facility staffing is inadequate

Licensing Program Analysts (LPAs) Kelly Dulek, Emily Peraldi, and Quoc Huynh conducted a subsequent complaint visit with the purpose of delivering findings for the above listed allegations. LPAs met with Administrator Robloe (Rob) Babasanta at 10:00AM. Entrance interview conducted. On 11/01/2024, LPA Dulek received a telephone call/voicemail from Administrator Babasanta at 12:06PM indicating an incident had occurred between two (2) residents at the facility. LPA spoke to Administrator and Health Services Director (HSD) on the telephone at 02:30PM. LPA arrived at the facility at 03:10PM to conduct a Case Management visit related to the reported incident. During the visit, LPA interviewed HSD at 03:12PM, LPA conducted a health and safety check tour of the facility at 03:19PM, and LPA reviewed and obtained copies of relevant documents. LPA then received a complaint related to the reported incident and conducted an initial complaint visit on 11/06/2024. During the visit, LPA interviewed Administrator and HSD, Report Continued on LIC 9099-C (p. 2) Substantiated as well as toured the facility and obtained copies of additional documents. On 11/14/2024, LPA, along with Long Term Care Ombudsman (LTCO) MaeRetha Coleman conducted a subsequent complaint investigation. During the visit, LPA and LTCO interviewed Administrator at 09:45AM and conducted a health and safety check tour of the facility at 10:38AM. Administrator was informed throughout the visits that the complaint was referred to Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Phillipe Ryan Miles for investigation. Investigator Miles obtained and reviewed copies of Ventura County Sheriff’s Office (VCSO) reports related to the incident. Investigator Miles also interviewed Administrator on 03/06/2025. Throughout the course of the investigation, LPA Dulek reviewed all documents and reports obtained. During today’s visit, LPA reviewed and obtained a copy of the Medication Administration Record (MAR) for Resident #1 (R1). The following was then determined: Allegation: “Neglect/lack of care & supervision – Resident 1 (R1) caused severe injuries to Resident 2 (R2) that led to the death of R2:” The complaint alleges that an incident occurred on the morning of 11/01/2024, which resulted in R2’s death. LPA Dulek received a telephone call on 11/01/2024. Administrator indicated to LPA that an incident had occurred between two (2) residents at the facility, which resulted in R2 passing away due to the injuries sustained. LPA conducted a case management visit on 11/01/2024; a written incident report was provided to the LPA during the visit. VCSO interviewed all staff working at the facility on the overnight shift when the incident occurred. Review of interviews revealed that during the overnight shift that took place from 10:00PM on 10/31/2024 to 06:30AM on 11/01/2024, Resident #1 (R1) was observed to be agitated. Initially, the facility charge nurse radioed for assistance in the shared room belonging to R1 and Resident #2 (R2) before midnight. Staff #1 (S1) and Staff #2 (S2), who were working as caregivers during the overnight shift responded to the call for assistance. R2 was non-ambulatory and required assistance with activities of daily living (ADLs) such as toileting and transfer assistance. R2 was attempting to get out of their bed at that time. S1 and S2 provided care to R2 and observed that R1 was awake and concerned with the commotion in their shared room. Staff reassured R1 that everything was okay before leaving the room. Around 03:30AM, staff saw R1 walking around the common areas. R1 had a staff radio in their hand, as well as the foot rest from a wheelchair. S1 and S2 attempted to calm R1 as R1 indicated they were hearing voices and seeing “somebody.” Staff indicated R1 was “inconsolable and agitated.” All 3 (three) staff working the overnight shift observed R1’s behaviors around 03:30AM. While two (2) Silverado staff walked away, leaving R1 in the common area, S1 agreed to walk R1 to their room and check the room for R1’s safety. R1 began swinging the wheelchair leg at S1, resulting in a scratch to S1’s left forearm. S1 was able to take the items from R1 Report Continued on LIC 9099-C (p.3) and R1 returned to their room at that time. S1 stated that R1 was “acting very dangerous” and S1 was scared that R1 would hurt someone. S1 requested the charge nurse to administer a PRN (as needed) medication to R1, however the charge nurse indicated that sometimes the medication does not work and the MAR indicated the medication was not administered. Around 04:30AM, while S1 and S2 were continuing to assist other residents, S2 heard a noise from the upstairs bistro area. The charge nurse radioed and indicated R1 had broken an upstairs window, but everything was okay. Staff found R1 in the common area covered in blood. R1 was agitated and would not allow staff to get close enough to R1 to assess for injury. The nurse called 9-1-1 and both VCSO, fire department, and emergency medical personnel responded promptly. When VCSO had secured the area and was present with R1, facility staff left the common area to go check on R1’s roommate, R2. Facility staff found R2 lying in their bed severely injured. Emergency personnel assessed R2 and pronounced R2 deceased. The cause of death was determined to be blunt force trauma. VCSO arrested R1 for R1’s involvement in R2’s death. Staff interviews revealed that R1 had been acting dangerously earlier in the evening, including physically assaulting S1, yet staff allowed R1 to return to their shared room unsupervised, where R1 physically assaulted R2 resulting in the death of R2. Based on interviews and record review, the preponderance of evidence standard has been met. Therefore, the allegation above is deemed SUBSTANTIATED at this time. Allegation: “Facility did not provide basic services to resident(s) in care:” The complaint alleges the facility did not protect R2 from their roommate, which resulted in R2’s death. As described above, staff indicated that on the night of the incident, R1 was “acting very dangerously” and S1 stated they were scared that R1 would hurt someone. Staff employed by the facility were aware that R1 had a history of aggressive behavior, which had previously prevented R2 from receiving care based on R1’s behaviors. R1 had a known behavior of arming themselves with pieces of metal found around the facility. On the night of the incident, R1 believed there were vampires in the facility and was hearing voices. Review of R1’s MAR revealed that R1’s PRN Lorazepam, which was ordered twice a day as needed for agitation, was not administered at all from 10/28/2024 – 11/01/2024 even though staff interviewed stated R1’s agitation was “out of control” during that time period. Interview revealed that on the night of the incident when S1 requested the nurse administer R1’s PRN Lorazepam, the nurse indicated it “sometimes didn’t work” and the medication was not documented as administered. Around 03:30AM on 11/01/2024, R1 attacked S1 with a metal wheelchair footrest, resulting in injury to S1. Staff attempted to de-escalate R1 and had threatened to call the police due to R1’s behaviors. However, staff did not call police until after R1 broke the window upstairs and staff found R1 covered in blood. Staff interviewed stated that R2 would have been defenseless Continued on LIC 9099-C (p.4) during any attack due to their mental impairment, limited communication and non-ambulatory status, yet staff still allowed R1 to return to their shared room throughout the night. Staff did not provide any additional safety checks inside R1 and R2’s room, even though R1 was acting erratically and R2 was unable to get out of bed without assistance. Based on interview and record review, the preponderance of evidence standard has been met, therefore the allegation above is deemed SUBSTANTIATED at this time. Allegation: “Facility did not reappraise resident(s) in care” and “facility retained a resident that required a higher level of care:” Record review revealed that upon admittance to the facility, R1’s diagnoses included, but were not limited to Parkinson’s Disease, Unspecified Psychosis not due to a substance or known, and unspecified dementia with behavioral disturbance. During a care conference on 05/02/2024, it was noted that R1 had increased hallucinations in addition to delusions. At that time, R1 was residing in a private room on the first floor. Management indicated that the lower floor is geared toward higher-functioning residents with dementia diagnoses and the upstairs area is designated for more advanced dementia and residents who require additional ADL care. Staff interviews revealed that R1 was moved upstairs to a shared room on 06/27/2024. Following the move to the second floor, R1 was noted with increased anxiety and agitation particularly later in the day, however R1 had a lower dosage of PRN medication prescribed for agitation at that time. On 08/30/2024, facility staff sent a request to R1’s physician indicating “pt mood is unstable” and R1’s physician ordered blood work. R1 visited the emergency room on 09/13/2024 due to syncope, orthostatic hypotension and seizure. On 10/17/2024, R1’s physician ordered an increased dose of Lorazepam twice daily as needed for agitation. Additionally, R1’s behaviors had changed more in the days and weeks leading up to 11/01/2024. The facility did have a form for Behavior Mapping dated 10/22/2024, with indications of R1 being awake in their room or awake in the hallway during the overnight hours. R1 was noted to be “withdrawn,” “anxious,” or “pacing” at these times. Staff interviewed stated R1s agitation the last three (3) or four (4) days has been “out of control” and “not re-directable.” On the night of the incident, all staff working were aware that R1 was “acting very dangerous” prior to the incident occurring, however, staff did not inform management nor intervene by calling 9-1-1 when R1 attacked S1 earlier in the evening. R1’s care plan was dated 04/14/2024; no new reappraisal nor care plan was assessed based on the observed changes in R1’s behavior. R1 was seen by Behavioral Health on 10/31/2024 and noted with “major depressive disorder” and document indicates “no cognitive impairment noted.” Based on interview and record review, the preponderance of evidence standard has been met, therefore the allegations above are deemed SUBSTANTIATED at this time. Report Continued on LIC 9099-C (p. 5) Allegation: “Facility staffing is inadequate:” The complaint alleges that on the overnight shift from 10/31/2024 to 11/01/2024, the facility did not have sufficiently trained staff present at the facility. Interview and staff schedule review revealed that during the overnight shift, there are typically two (2) care staff scheduled and one (1) charge nurse working. Interview with S2 revealed that rounds have been taking “a little bit longer” due to low staffing. On the overnight shift on 10/31/2024, the facility did have a charge nurse working but had only one (1) Silverado care staff available. As a result, the facility scheduled an outside-agency staff to work as the second caregiver. Staff #1 (S1) is employed through 1 Heart Caregiver Services and does not work directly for Silverado Senior Living. Interview revealed that S1 had filled in as a caregiver at Silverado multiple times prior to the night the incident occurred. When the LPA inquired about training for S1, management staff indicated they assumed S1 was trained through the caregiving agency. Management stated that since S1 is not directly employed by Silverado, Silverado does not conduct regular training for S1. Training records for S1 were reviewed during the investigation. S1 did have a 2-hour orientation with the caregiving agency but did not meet initial or ongoing training requirements as outlined in Title 22 regulation. Based on interview and record review, the preponderance of evidence standard has been met, therefore the above allegation is deemed SUBSTANTIATED at this time. A $500 immediate civil penalty is assessed today. The Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and/or 1569.49(f). Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies are cited (refer to LIC9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 25, 2025 · control 29-AS-20241105163045

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(2) · Plan of correction due date: Mar 26, 2025

87464 Basic Services (f) Basic services shall at a minimum include: (2) safe and healthful living accommodations and services, as specified in Section 87307, Personal Accommodations and Services This requirement is not met as evidenced by: Based on interview and record review, the facility did not comply with the above cited section, as facility staff did not keep R2 safe from R1, resulting in R2's death, which posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 25, 2025

Plan of correction: Administrator agreed to reassess residents and ensure proper placement with roommates and implement appropriate safety measures for all residents in care. Statement of understanding will be sent to CCLD by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(a) · Plan of correction due date: Mar 26, 2025

87463(a) The pre-admission appraisal ...shall be updated in writing as frequently as necessary...to note significant changes in condition...and to keep the appraisal accurate...shall be referred to as the reappraisal. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as staff were aware R1's mental condition and behavioral expressions had changed, however, no reappraisal was completed, which posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 25, 2025

Plan of correction: Administrator agreed to reassess residents and ensure proper placement with roommates and implement appropriate safety measures for all residents in care. Statement of understanding will be sent to CCLD by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Mar 26, 2025

87411 (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above, as the facility was short staffed and utilizing agency staffing, S1 was not trained per regulation, and staff did not act competently, which posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 25, 2025

Plan of correction: Administrator agreed to ensure all agency staff utilized at the facility has sufficient training. Administrator also agreed to provide training to all staff on the topics of appropriate de-escalation behaviors, early intervention techniques, and medication interventions. Training will be ongoing and statement of understanding related to training will be sent to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Quoc Huynh, Kelly Dulek, and Emily Peraldi arrived unannounced at 9:58AM for a required one year visit. The LPAs met with Administrator Robloe Babasanta and explained the reason for the visit. Entrance interview conducted. At 11:00AM, the LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: COMMON AREAS: The facility is a two-story building. On the first floor, there are the kitchen facilities, dining room, Bistro, laundry rooms, Wellness Center, fitness center, office spaces, and common restrooms. On the second floor, there is a beauty salon, spa, Wellness Center, second floor dining, a private dining room, several activity spaces, office spaces and common restrooms. The LPAs observed common areas to be clean and in good condition. There were no obstructions and/or tripping hazards throughout the facility. There were cameras in the common areas, outdoor courtyard, and exterior perimeter. Required postings were found in the hallway on the first floor. There are fire extinguishers throughout the facility, which were serviced 07/15/2024. Fire alarm system is tested annually with the last inspection on 06/10/2024 by Smart Systems Technologies Incorporated. Report Continued on LIC 809-C There are three outdoor gated courtyards; two are on the first floor and one is on the 2nd floor. The LPAs observed outdoor furniture, with a covered shaded area for residents. There were no bodies of water observed during today’s visit. KITCHEN: The main kitchen is located on the 1st floor. Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. Facility uses Sysco Foods for food deliveries, and food delivery takes place twice a week. There was a sufficient supply of perishable and non-perishable food. Food appeared to be of good quality RESIDENT ROOMS: The LPAs observed randomly selected rooms on the first and second floor and no immediate health or safety hazards was observed. Restrooms were clean, with properly installed grab-bars in resident bathrooms and non-skid strips in shower tubs. Appropriate furniture was also observed in the units. Water temperature was tested throughout the units and measured between 114.2 degrees F and 115.2 degrees F, which is within the required range per regulation. RECORDS: Resident records were reviewed at 1:45PM. The LPAs reviewed five files for, but not limited to: admissions agreements, medical assessment, updated appraisals. Resident records reviewed were in order at this time. Personnel records were reviewed at 2:15PM. The LPAs reviewed personnel records, but not limited to: job application, health assessments, TB results, criminal record statements and clearances, first aid/CPR certification. Staff files reviewed were in compliance with regulation at this time. Report Continued on LIC 809-C MEDICATION: Medications review began at 3:15PM. The LPAs reviewed medications for four residents. Medications are maintained locked inaccessible to residents in the Wellness Centers located on the first and second floor. Four out of four resident medications reviewed were documented and stored in compliance with regulation at this time. INFECTION CONTROL/EMERGENCY DISASTER: LPAs reviewed the facility's infection control plan and Emergency Disaster plan. LPAs noted that the facility is in compliance with regulation. Facility conducts emergency disaster drills as required with drills conducted monthly. Four residents and five staff were interviewed. No complaints noted. No deficiency cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 25, 2025

Allegation investigated: Resident care needs not met. Staff did not initiate meeting with resident's responsible person.

Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced subsequent complaint visit to this facility to deliver investigation finding. LPA met with Executive Director and reason for the visit was stated. On 09/14/2023, Community Care Licensing Division (CCLD) received a complaint with the above allegations. On 9/20/2023, investigation was initiated from approximately 10:30am – 2pm; records were reviewed; interview was conducted with potential witnesses, and staff; ten (10) random resident rooms and common areas were toured. Attempt was made to interview residents during the room inspection. Following is a summary of the investigation findings: Regarding allegations, “Resident care needs not met” and “Staff did not initiate meeting with resident's responsible person”– It was alleged that staff did not follow through in addressing R1’s change in condition. It was also reported that subsequent care plan meeting was never initiated by facility staff. (cont.to LIC9099c). Substantiated Interview conducted with staff, potential witnesses and records reviewed revealed the following: R1 moved into this facility on 05/23/2022. A care plan meeting was initiated by facility staff on or about 06/10/2022 and another in 8/2022. Service plans completed by facility staff dated 5/25/2022; 05/31/2022; 09/06/2022; 11/03/2022; 11/30/2022; 03/21/2023 and 05/31/2023 were observed on file and reviewed. The Service Care Plans did not have any signatures to confirm who completed the evaluation and who was present during the evaluations. Potential witness interviewed revealed that beginning 10/2022 – 9/14/2023 several care plan meetings were initiated by R1’s responsible person due to the increasing decline observed in R1’s condition. On or about 07/13/2023, former Executive Director Stephanie Funderburg reported to R1’s responsible person that they would conduct a 72-hour behavioral mapping to address any issues or concerns. No documentation or record of this was found on file. On or around 09/07/2023, R1 was evaluated by Silverado team, and it was agreed to have R1 tested for possible UTI due to the increasing behavioral changes observed. On 09/13/2023, R1 sustained a fall. Interviews conducted revealed that the facility did not follow through with sending labs out for UTI test results. R1's responsible person was informed by former Director of Health Services - Hope Langston that the lab never picked up the urine sample. No further action was taken by facility. On 09/14/2023, R1's responsible person contacted the physician and reported the increased decline observed and current symptoms; R1 was transferred to the nearest ER per physician orders; R1 was admitted to Los Robles Hospital on 09/14//2023 – series of tests were conducted. R1 tested positive for UTI and chest x-ray indicated pneumonia. Based on the above gathered, there is sufficient evidence to support the allegations; therefore allegations “Resident care needs not met” and “Staff did not initiate meeting with resident's responsible person”; is deemed Substantiated. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies cited (refer to LIC 809-D): Exit interview conducted. A copy of the report and appeal rights provided. Potential witness interviewed reported that R1 was observed in dirty and smelly clothing on several different occasions. Staff interviewed denied allegations and reported that all residents are assisted with dressing when needed. Staff reported that if a resident is observed with soiled clothing staff would attempt to change resident. Staff expressed that residents do have accidents daily and are changed and cleaned when observed. Staff expressed that if a resident becomes combative, they would give resident space and allow resident to calm down and not force resident to change. Staff reported that residents are not left unattended and are checked and cleaned regularly. Facility common areas, and random resident rooms were toured on 9/20/2023; and on 03/29/2024 during the annual inspection. During these visits, random resident rooms and common areas toured did not observe to be unkept and were odor free at time of visits. Other potential witnesses interviewed shared that the facility is kept clean, odor free and facility residents observed in the common areas to be clean and not with soiled clothing. Based on the above gathered, although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegations “Staff left resident in soiled clothing; Staff not keeping resident’s room free from odor and Staff not keeping resident’s room clean” are deemed UNSUBSTANTIATED at this time. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Dec 23, 2024 · control 29-AS-20230914154258

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Dec 27, 2024

Observation of the Resident:The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply in the section cited above. Former resident (R1) was observed to be declining however eventually hospitilized on 9/14/2023 and tested positive for UTI and pneumonia. This posed a potiential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 23, 2024

Plan of correction: Current Executive Director reported that the facility residents are observed and monitored regularly and any significant change is reported accordingly. Submit a written self certification of understanding the regulation cited and your plan to ensure future compliance.Copy of in-service due by 1/3/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87467(a)(3) · Plan of correction due date: Dec 23, 2024

Resident Participation in Decisionmaking: (a)(3) - Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative,if any appropriate facility staff, and a representative of the resident’s home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility.the state’s words, verbatim · CDSS document, Dec 23, 2024

Plan of correction: Current Executive Director stated the facility policy is that the residents service care plans be reviewed every 6 months or sooner if there is a significant change in condition/hospitalization and signed by all parties involved in the meeting. According to new ED that is the procedure they follow currently. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident’s condition, or once every 12 months whichever occurs first...

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kelly Dulek conducted a Case Management - Incident visit regarding a self-reported incident which took place on 11/01/2024. LPA met with the facility Director of Health Services Heather Hampel and explained the reason for the visit. LPA Dulek received a telephone call/voicemail from Administrator Robloe (Rob) Babasanta at 12:06PM on 11/01/2024. LPA returned Administrator's call and spoke with ED Babasanta and Heather Hampel via telephone at 02:30PM. Administrator indicated there had been an incident at the facility involving 2 (two) residents at the facility, who are roommates. On 11/01/2024, at approximately 04:30AM, facility staff discovered Resident #1 (R1) in the facility common area; R1 appeared agitated and had blood on their body. Facility staff called 9-1-1. Both Ventura County Fire and Ventura County Sheriff's Office responded at 04:44AM. Staff then discovered Resident #2 (R2) was injured in the room R1 and R2 shared. Ventura County Fire tended to R2, who was subsequently pronounced deceased at the facility. Ventura County Sheriff detained R1 related to the incident. During LPA's visit today, LPA interviewed Director of Health Services (DHS) at 03:12PM, toured the facility with DHS at 03:19PM and LPA obtained copies of pertinent documents. No immediate health and safety hazards were identified during facility tour. Facility management was informed that this incident was referred to Community Care Licensing Division's Investigations Branch (IB). LPA and/or IB Investigator will return at a later date regarding this incident. No deficiencies cited during today's visit. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 1, 2024

Allegation investigated: Staff are sleeping while on working hours

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation with the purpose of delivering findings for the above noted allegation. LPA met with Director of Health Services Heather Hampel and explained the reason for the visit. During the initial visit conducted on 08/23/2024, LPA interviewed Executive Director (ED) at 10:48AM and LPA conducted a health and safety check tour of the facility at 11:25AM. LPA interviewed staff at 01:20PM, 04:00PM, and 04:15PM and obtained copies of pertinent documents. Throughout the course of the investigation, LPA reviewed documents and interviewed staff telephonically. The following was then determined: It was alleged that staff are sleeping during the overnight (NOC) shift, however, no specific information was provided related to staff members involved nor a time frame indicated. LPA interviewed staff and Report Continued on LIC 9099-C Unsubstantiated management and attempted to interview residents. Management indicated that there had been reports around January or February that staff were sleeping during their shifts. Management proactively conducted night audits and observations of the NOC staff. As a result of the audits, 2 (two) staff were terminated from employment at that time. LPA confirmed that ED was first associated with the facility on 01/22/2024 and ED stated that this had occurred around the time of his employment with the facility. Staff interviews revealed that there have been no other staff observed sleeping while on shift, nor have any staff heard of this occurring in the last 6 (six) months. NOC care staff indicated they work together during the shift to ensure both staff are awake, alert, and caring for the residents properly. Additionally, a nurse works during the NOC shift, who walks the building and frequently checks in with the care staff to ensure there are no problems or concerns. All staff interviewed indicated it would be nearly impossible for staff to sleep on NOC shift with the way they are currently operating. At the time the complaint was received and for the previous 6 (six) months, there were no reports of staff sleeping on NOC shift. Residents observed appeared well cared for and content but were unable to be interviewed. Based on interview, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “staff are sleeping while on working hours” is deemed UNSUBSTANTIATED at this time. No deficiencies cited during this visit. Exit interview conducted with Director of Health Services. A copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 10, 2024 · control 29-AS-20240821111712

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct an annual continuation visit. Upon arrival, the LPA met with Executive Director Robloe (Rob) Babasanta. Entrance interview conducted. This visit and related report serve as both the annual continuation and legal non-compliance visit. The licensee was placed on frequent monitoring for a period of two years during a Non-Compliance Conference that took place on 10/26/2022. The last facility visit was conducted on 03/29/2024. PHYSICAL PLANT: Beginning at 11:25AM, the LPA and the Executive Director briefly toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. During facility tour, staff were observed engaging with residents in activities. LPA spoke with various residents throughout the facility tour and no concerns were observed nor communicated. Fire extinguishers throughout the community were observed to be fully charged and last serviced 07/15/2024. Annual fire protection inspection was conducted by Smart Systems Technologies Incorporated on 06/10/2024. Proof of correction for 2 items noted as deficient was provided to the LPA. FILES: Beginning at 11:50AM, the LPA reviewed 5 (five) resident files for but not limited to: physician's report, needs and service appraisals, personal rights. All 5 (five) resident files reviewed contained all required documents. Beginning at 12:27PM, The LPA reviewed a selection of 5 (five) staff files for documents including, but not limited to health screening, TB test results, background clearance, and training records. All staff records reviewed were observed to be complete and in compliance with regulation at this time. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's Report Continued on LIC 809-C infection control plan and the facility's emergency disaster plan. The facility's policies and procedures as it pertains to infection control are adequate. LPA reviewed the facility's emergency disaster plan, which was observed to be complete and updated annually as required. The facility conducts emergency disaster drills on each shift quarterly, with the last fire drill documented on 07/16/2024. MEDICATION REVIEW: Began at 02:31PM, LPA and Director of Health Services Heather Hampel reviewed medications for 5 (five) residents. All 5 (five) of 5 (five) residents' medications reviewed were stored and documented in compliance with regulation at the time of the visit. INTERVIEWS: Throughout today's visit, LPA interviewed 3 (three) staff and multiple residents. No concerns were noted. DOCUMENTS OBTAINED: During today's visit, LPA obtained a copy of the facility's liability insurance and staff schedule. No citations issued. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Aug 23, 2024

Allegation investigated: Physical Abuse - Resident #1 (R1) was physically and emotionally injured by Staff #1 (S1) while under the care and supervision of the facility. Conduct Inimical - Staff #1 (S1) was arrested and charged with misdemeanor elder abuse and being under the influence of a controlled substance.

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Administrator Rob Babasanta and explained the reason for the visit. On 02/28/2024, the Department received a complaint regarding allegations of physical abuse and conduct inimical. Resident #1 (R1) was physically and emotionally injured by Staff #1 (S1), while under the care and supervision of the facility; and S1 was arrested and charged with a misdemeanor elder abuse and being under the influence of a controlled substance. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Philippe Ryan Miles. (continued on LIC9099-C) Substantiated (continued from LIC9099) It was noted that the incident was self-reported by the facility on 02/09/2024. Licensing Program Analyst (LPA) Teresa Camara conducted two Case Management visits regarding the incident on 02/12/2024, from 9:32am to 11:45am and on 02/14/2024, from 9:09am to 1:20pm. During the visits, LPA Camara met with the Administrator, reviewed and obtained records, toured the facility, conducted staff interviews, and attempted to interview R1. The LPA also reviewed a video of the incident. The incident report documented that on 02/09/2024, at approximately 8:15am, Resident #1 (R1) was receiving assistance from Staff 1 (S1). S1 was observed to handle R1 roughly, slap R1, grab R1 by the neck and shoulder, verbally threaten R1, and push R1 in the hallway. The Ventura County Sheriff's Office was called and ultimately arrested S1. On 02/29/2024, from 9:20am to 10:30am, LPA Camara conducted an initial complaint investigation visit and health and safety check. The LPA met with co-Administrator Rob Babasanta and explained the reason for the visit. At 9:40am, the LPA requested and obtained documents. At 9:45am, the LPA conducted a physical plant tour. The LPA advised that further investigation would be conducted by Community Care Licensing Division (CCLD) Investigations Branch (IB) Investigator Philippe Ryan Miles. On 04/22/2024, from approximately 10:56am to 1:32pm, Investigator Miles attempted to conduct an interview with R1 (who was unable to be interviewed due to diagnosis of advanced dementia/Alzheimer’s disease/unable to communicate), conducted interviews with Administrator, Director of Health Services, and Staff #1 (S1); on 05/03/2024, 05/14/2024, and 05/20/2024, attempted to interview former Staff #2 (S2), and left voice messages. In addition, Investigator Miles reviewed Superior Court of California, County of Ventura VCIJIS Case#: 202403859 court documents, Ventura Sheriff’s Department VSD Report#: 2024-16948, facility surveillance video, and facility file documents pertaining to the investigation. (continued on LIC9099-C page 3) (continued from LIC9099-C page 2) According to the incident report submitted by the facility, on 02/09/2024, at approximately 8:15am, S1 assisted R1 while changing R1’s clothes. S2 walked in to assist S1 who became aggressive towards R1. R1 spat on S1, who then aggressively pulled R1’s pants down. S1 pushed R1 to a seated position on the bed. R1 slapped S1. S1 slapped R1 in the face, “grabbed R1’s face and demanded R1 apologize.” S2 requested S1 to move away and would take care of R1. While S2 was assisting R1, S1 had their arm on R1’s neck and shoulder. S1 “was saying you think you are stronger than me.” S2 told S1 to leave the room. R1 went outside the room to sit down on the bench. R1 did not want to go with S1 who began pulling R1 down the hallway causing R1 to almost lose balance. Staff reported the incidents to management. The investigation revealed that due to the incident on 02/09/2024, R1 sustained a small, fresh laceration to their left arm. The laceration was approximately one centimeter in length and drew blood. During the VSD interview and evaluation of S1, Deputy Barrios observed signs and symptoms of S1 “being under the influence of a controlled substance.” S1 displayed “pinpoint pupils in indoor lighting, was extremely fidgety, and was not able to provide an accurate or chronological sequence of events from start to finish. S1’s statements were fragmented and while S1 spoke, the deputy observed a “very visible and pronounced neck pulse.” S1 denied covering R1’s mouth, grabbing the back of neck, or using S1’s forearm to push R1 down to the bed. S1 stated they placed their hand near R1’s mouth to prevent R1 from spitting on S1, but “was adamant that at no time did they (S1) cover R1’s mouth.” S1 stated S1 assisted R1 down the hallway to the dining hall but was not “dragging” R1 “rather [than] assisting R1 with R1’s movement using S1’s body weight.” A review of the video surveillance showed S1 “mistreating, dragging, taunting, slapping, and air kicking” R1 in the hallway. The VSD conducted an investigation and the VSD arrested S1 and transported S1 to the Pre-Trial Detention Facility (PTDF) where S1 was booked for PC 368(b)(1) for Elderly Abuse and HS 11550(a) for Under the Influence of a Controlled Substance. (continued LIC9099-C page 4) (continued from LIC9099-C page 3) On the allegation “Physical Abuse – Resident #1 (R1) was physically and emotionally injured by Staff #1 (S1) while under the care and supervision of the facility” – On 02/09/2024, the day of the allegation, S2 reported to the Director of Health Services, that S2 witnessed S1 physically abuse R1 while changing R1’s soiled clothing. According to Ventura Sheriff’s Department (VSD) Report#: 2024-16948, S2 told the deputies S2 witnessed S1 slap R1 on the face, and actively applied pressure using S1’s forearm against R1’s chest while on R1’s bed. The Director of Health Services showed the captured surveillance video to the deputies of S1 “mistreating, dragging, taunting, slapping, and air kicking” R1. The VSD arrested S1 and transported S1 to the Pre-Trial Detention Facility (PTDF) where S1 was booked for PC 368(b)(1) for Elderly Abuse and HS 11550(a) for Under the Influence of a Controlled Substance. S1 claimed S1 did not physically abuse R1. Based on the interviews conducted, supporting documents, and video surveillance; there is sufficient evidence to support the allegation of Physical Abuse. Therefore, the allegation is deemed Substantiated at this time. On the allegation “Conduct Inimical – Staff #1 (S1) was arrested and charged with misdemeanor elder abuse and being under the influence of a controlled substance” - On 02/09/2024, the day of the allegation, when the VSD was at the facility questioning S1 regarding R1, the VSD Deputy observed signs and symptoms of S1 “being under the influence of a controlled substance.” During the evaluation of S1’s urine sample collected, S1 tested “presumptive positive for amphetamines and opiates.” S1 was transported to the Pre-Trial Detention Facility (PTDF) where S1 was booked for PC 368(b)(1) for Elderly Abuse and HS 11550(a) for “Under the Influence of a Controlled Substance.” Based on the fact that S1 tested positive for being under the influence while working at the facility, there is sufficient evidence to support the allegation of Conduct Inimical; therefore, the allegation is deemed Substantiated at this time. A $500 immediate civil penalty is assessed today. The Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, May 31, 2024 · control 29-AS-20240228102452

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jun 7, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... This requirement was not met as evidenced by: Based on interviews, records review, and video surveillance review, the licensee did not comply with the section cited above. Video surveillance showed S1 “mistreating, dragging, taunting, slapping, and air kicking” R1, which posed anthe state’s words, verbatim · CDSS document, May 31, 2024

Plan of correction: Licensee will submit a plan how they will ensure the personal rights of residents are not violated. Submit to CCL by 6/7/2024. immediate health and safety risk to residents in care.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.58(a)(2) · Plan of correction due date: Jun 3, 2024

§1569.58 Persons prohibited from being a licensee, owning beneficial interest in licensed facility, or holding certain positions or employment; grounds; notice; removal; appeal; petition for reinstatement (a) The department may prohibit from employing, or continuing the employment of, ...any employee, prospective employee, or person who is not a client and who has done any of the following: (2) Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the State ofthe state’s words, verbatim · CDSS document, May 31, 2024

Plan of correction: S1 was terminated by the facility. S1 was charged with HS 11550(a) for Under the Influence of a Controlled Substance. Plan of correction complete. California. This requirement is not met as evidenced by: Based on drug testing results, the licensee did not comply with the section cited above. S1 tested positive for being under the influence of a controlled substance while working at the facility, which posed an immediate health and safety risk to residents in care.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced required annual visit. Upon arrival the LPA met with Rob Bassanta the new Executive Director. Reason for LPA's visit was explained. At approximately 1pm the LPA and the Executive Director toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. COMMON SPACES: The facility is a two-story building. The kitchen, dining room, Bistro, laundry rooms, office spaces, and common restrooms are located on the first floor. The beauty salon, spa, Wellness Center, second dining, a private dining space, activity spaces, office spaces and common restrooms located on second floor. The LPA observed common areas to be clean and in good condition. There were no obstructions and/or tripping hazards throughout the facility. Cameras observed in the common areas, outdoor courtyard, and exterior perimeter. Required postings observed in the lobby and hallway area. Fire extinguishers observed throughout the facility, which were serviced on 7/6/2023. Carbon monoxide detector tested and observed functioning. Facility smoke detectors are hardwired and tested. There are enclosed patio areas, one on the first floor and one on the second floor. LPA observed outdoor furniture, with a covered shaded area for residents use. There were no bodies of water observed during today’s visit. Delayed egress was tested on all exits and they were operational at the time of the visit. KITCHEN: The main kitchen is located on the first floor. Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. Facility food delivery takes place twice a week. There was a sufficient supply of perishable and non-perishable food. Food appeared to be of good quality. Carpet in the dining room observed to be stained. Executive director reported that the dining room carpet is frequently cleaned and is on schedule for cleaning in the next couple of days. BEDROOMS: The LPA observed a random selection of resident rooms, and rooms were furnished appropriately with clean linens, furnishings and sufficient lighting. RESTROOMS: The LPA observed a random selection of resident restrooms and all were observed clean, in operating condition with grab bars, and non-skid surfaces. Due to time constraints, the annual inspection will be completed on a follow-up visit. No health and safety hazards. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Mar 29, 2024

Allegation investigated: Staff are prohibiting resident from receiving family's phone calls.

Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced subsequent visit to deliver the findings pertaining to the allegation listed above. The LPA met with the Director of Healh services, Heather Hampel and explained the reason for the visit. On 02/12/2024, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced initial 10-day visit to investigate allegations listed above. The LPA met with the Administrator Sabrina Pegross and explained the reason for the visit. At 11:50 a.m. the LPA requested records pertaining to the complaint, and interviewed the Administrator from 12:00 p.m. to 12:30 p.m. The LPA interviewed the resident #1(R1) from 12:45 to 1:10 p.m. At the time of the R1’s interview, R1 appeared to be alert and oriented to questions during the interview. Continues on LIC 9099C... Substantiated Staff are prohibiting resident from receiving family phone calls. On the allegation that the staff are prohibiting the residents from receiving phone calls, the Reporting Party’s (RP) concern is that the R1 is not being allowed to receive phone calls (on the facility’s phone) from family members. To investigate the allegation the LPA attempted to interview the family members to ascertain the information received by the RP. The LPA made three calls between 02/12/2024 and 02/16/2024 at approximately 1:21 p.m.,1:35 p.m. and 12:30 p.m., however the calls went to voicemail. LPA Urena left voicemail. On 02/22/2024, the LPA communicated with family members from approximately 10:38 a.m. to 11:10 a.m. The family members stated that on several occasions, family members attempted to communicate with R1 via the facility’s phone, however they were told by facility staff that R1 was not available, and that the staff would have R1 called them back right away. The family members added that they never received the call back as they had expected. The family members further stated that they were able to speak with the administrator on 02/05/2024, and that on this date the administrator stated that they were not aware of the calls, and that they would interview facility staff about the calls that were never transferred to R1. Finally, R1’s family members stated that after the phone call with the administrator 02/05/2024, they have been able to communicate with R1 when they call the facility. The LPA interviewed the facility’s administrator about the facility’s policy on phone calls. The Administrator stated that the facility has two cell phones available for residents’ use. If a family member/calling party calls the facility to communicate with a resident, the facility will bring one of the cell phones to the resident. Or if a resident wishes to use the cell phone, the staff will bring a cell phone to the resident. Sometimes the resident may have to wait for the cell phone to be available, if one of the two cell phones are being used. Based on the information obtained through the interviews, the facility staff did not transfer calls to residents as expected, which prevented the family members from communicating with the resident. Therefore, the allegation that staff are prohibiting resident from receiving family phone calls, is Substantiated at this time. Pursuant to Title 22 Regulations, deficiencies were cited (refer to LIC 9099-D). Citations were issued. Exit interview conducted, a copy of the report, and Appeal Rights was issued.the state’s words, verbatim · CDSS document, Feb 22, 2024 · control 29-AS-20240206125039

From the deficiency page — Deficiency type: Type B · Section cited: CCR 85072(a)(b) · Plan of correction due date: Mar 8, 2024

85072Personal Rights (a)In addition to Section 80072, the following shall apply. (b)The licensee shall insure that each client is …personal rights. To have access to telephones in order to make and receive confidential calls, provided that such calls do not infringe upon the rights of other clients and do not restrict availability of the telephone during emergencies. This requirement is not met as evidenced by: Based on the information obtained through interviews, the licensee did not comply in the section cited above, as facility staff did not provide family members with the opportunity to communicate with R1, which may pose a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 22, 2024

Plan of correction: The licensee will submit plan how they will ensure residents receive calls from calling parties in a timely manner. Submit the plan of correction to the department via email by 03/08/2024.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent Case Management - Incident visit regarding a self-reported incident which took place on 2/9/2024. LPA met with the facility Administrator Sabrina Pegross and explained the reason for the visit. On 2/9/2024, at approximately 8:15 a.m., Resident 1 (R1) was receiving assistance from Staff 1 (S1). S1 was observed to handle Resident 1 (R1) roughly, slap R1, grab R1 by the neck and shoulder, verbally threaten R1, and push R1 in the hallway. The Ventura County Sheriff's Office was called and ultimately arrested S1. During LPA's visit today, 2/14/2024, LPA interviewed staff at 9:10 a.m., 9:25 a.m., 9:49 a.m., 10:06 a.m., 10:19 a.m., and 11:21 a.m. The Administrator stated they are still working with their IT department to get a copy of the video they captured in the hallway of part of the incident. They will forward the video to the Sheriff and CCL once they are able to get it copied. LPA may need to return at a later date regarding this incident. No deficiencies were observed. A copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 14, 2024

Allegation investigated: Staff do not provide daily activities for resident.

Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced initial 10-day visit to investigate allegation listed above. The LPA met with the Administrator Sabrina Pegross and explained the reason for the visit. At 11:30 a.m. the LPA requested records pertaining to the complaint, and interviewed the Administrator from 12:00 p.m. to 12:30 p.m. The LPA interviewed the resident #1(R1) from 12:45 to 1:10 p.m. At the time of the R1’s interview, R1 appeared to be alert and oriented to questions during the interview. Staff do not provide daily activities for residents. On the allegation that staff are not providing daily activities for residents, the LPA interviewed the Administrator about the activities offered to residents. The Administrator provided a monthly calendar for activities available to residents. Continues on LIC 9099C... Unsubstantiated The LPA reviewed three Activity Calendars for the month of February. The facility offers three types of activities throughout the day: Sensory, Social, and Enrichment. The activities are designed to provide different types of engagement for residents (depending on the ability). The LPA observed a group of residents attending an activity at around 11:00 a.m. The activity was called “Brain Games”. Additionally, the Administrator provided pictures of R1 participating in at least two different activities in two separate dates. The R1’s interview revealed that the staff are very nice and do assist the R1 to walk. Based on the information obtained through interviews and record review, the allegation that the staff do not provide daily activities, is deemed Unsubstantiated at this time. Exit interview was conducted, and a copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 12, 2024 · control 29-AS-20240206125039

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Teresa Camara conducted a Case Management - Incident visit regarding a self-reported incident which took place on 2/9/2024. LPA met with the Director of Health Services (HSD) Heather Hampel, RN (registered nurse) and explained the reason for the visit. During LPA's visit the administrator was not at the facility. On 2/9/2024, at approximately 8:15 a.m., Resident 1 (R1) was receiving assistance from Staff 1 (S1). S1 was observed to handle Resident 1 (R1) roughly, slap R1, grab R1 by the neck and shoulder, verbally threaten R1, and push R1 in the hallway. The Ventura County Sheriff's Office was called and ultimately arrested S1. During LPA's visit today, 2/12/2024, LPA met with HSD at 9:35 a.m., reviewed records at 9:45 a.m., toured the facility at 10:04 a.m., attempted to interview R1 at 10:21 a.m. and interviewed HSD at 10:26 a.m. At 11:20 a.m. HSD showed LPA video they caught of part of the incident in the hallway. The HSD is working with their Information Technology (IT) department to get copies of the video for the Sheriff and CCL. LPA will need to return at a later date to continue the investigation. No deficiencies were observed. A copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 12, 2024

Allegation investigated: Staff did not refund fees according to the resident's admission agreement Staff are billing resident for services not provided

Licensing Program Analyst (LPA) Elsie Campos arrived unannounced to conduct an initial complaint visit for the above allegations. Upon arrival, the LPA met with Executive Director (ED) Sabrina Pegross and explained the reason for the visit. During today's visit, the LPA along with the ED conducted a tour of the facility to ensure there are no health and safety concerns, conducted an interview with the ED at 11:00 a.m., conducted a file review at 11:20 a.m., and obtained copies of the census, staff schedule, and other pertinent documents relevant to the investigation. Unsubstantiated Regarding the allegation, it was alleged that staff did not refund fees according to the resident's admission agreement. Resident moved into the facility on 8/30/2023. Interviews revealed that the resident and their responsible party (RP) informed staff and moved out of the facility on 10/31/2023 without a written 30 day notice, 63 days after move in. It was confirmed that on 9/20/2023, the RP was provided a credit as a courtesy, in the amount of $6,616.77 to help the resident avoid paying rent at two different facilities during the moving transition from the resident’s previous facility to Silverado Thousand Oaks. Approximately 63 days later, the RP made the decision to move out; as such, per the admission agreement ‘Termination by Resident’ it indicates “you may terminate this Agreement at any time, with or without cause, by giving the Administrator of the Community or his/her designee thirty (30) days prior written notice of termination. You need not to cite a specific reason for termination". A written notice was not received, and the RP moved forward with moving the resident out of the facility on the same day a verbal notification was given by the RP to the facility of the resident’s plan to move out, 10/31/2023. A review of the admission agreement revealed a statement, stating that parties understand that ‘the Administrative Fee of $10,000 is partially refundable based on the time of discharge from the community, in this case the resident moved out after the 60th day of residing at the facility as they moved in on 8/30/2023 and moved out on 10/31/2023 which puts the resident in the refund window of 61-90 days following move-in: allowing a 40% refund of the Administrative Fee after a $500 fee is deducted based on the agreed terms in the admission agreement. The refund for the Administrative Fee is to be issued within thirty days (30) of submitting written notification to move-out. However, a 30 day written notice was not received by the facility and instead a verbal notice was accepted on 10/31/2023 therefore making the end of the 30 days effective December 1st, 2023. Based on the evidence received, there is insufficient evidence to support the allegation. The above allegation is Unsubstantiated at this time. Continued on LIC 9099-C Regarding the allegation, it was alleged that staff are billing resident for services not provided. Documentation revealed that resident moved into the facility on 8/30/2023. Interviews revealed that the resident and their responsible party (RP) informed staff and moved out of the facility on 10/31/2023 without a written 30 day notice, 63 days after move in. It was confirmed that on 9/20/2023, the RP was provided a credit as a courtesy, in the amount of $6,616.77 to help the resident avoid paying rent at two different facilities during the moving transition from the resident’s previous facility to Silverado Thousand Oaks. Approximately 63 days later, the RP made the decision to move out; as such, per the admission agreement ‘Termination by Resident’ it indicates “you may terminate this Agreement at any time, with or without cause, by giving the Administrator of the Community or his/her designee thirty (30) days prior written notice of termination. You need not to cite a specific reason for termination”. A written notice was not received by the facility from the RP, and the RP moved forward with moving the resident out of the facility on the same day a verbal notification was given by the RP to the facility of the resident’s plan to move out, 10/31/2023. A review of the Admission Agreement revealed that the RP signed the admission agreement on 8/30/2023 and the resident moved in on the same day, acknowledging that “[they] parties have read and understood the Agreement, including its exhibits and attachments, and agreed to abide by the terms”. In this case the resident moved in on 8/30/2023 and moved out on 10/31/2023 without providing a written 30 day notice and instead a verbal notice was accepted by the facility on 10/31/2023 therefore making the end of the 30 days effective December 1st, 2023. which makes the RP responsible for the proceeding 30 days of fees generated for room and care, up until December 1st, 2023. Based on the evidence received, there is insufficient evidence to support the allegation. The above allegation is Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 19, 2023 · control 29-AS-20231213094351

Allegation investigated: Facility Staff did not follow proper reporting requirements.

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint visit to investigate the allegation listed above. Upon arrival LPA met with Administrator Sabrina Pegross and explained the reason for the visit. At approx. 10:30am, LPA conducted physical plant, interviewed staff and reviewed and obtained copies of pertinent documentation relevant to the investigation. It was reported that, Facility Staff did not follow proper reporting requirements as it was alleged that Resident #1 (R1)'s responsible party requested a written report pertaining to an incident that occurred on 10/29/2023. Interviews conducted and records review reflected that the facility had self-reported an incident to the Department on 10/30/2023, which stated that on 10/29/2023, R1 and Resident #2 (R2) were involved in a verbal altercation, and R1 stated that R2 had slapped them on the back of the head. Staff separated both R1 and R2 and no further incident or injuries were noted. The incident report also indicated that R1's responsible party and MD were notified of the incident. Substantiated Continued from 9099 On 10/30/2023, Staff #1 (S1) called R1's responsible party and informed them of the incident that had occurred . Additionally , on 10/30, R1's responsible party visited R1 at the facility and spoke with Staff #2 (S2) and Staff #3 (S3) in person in regards to the incident. On 11/17/2023, the responsible party requested a detailed written report of the incident. S1, S2 and S3 verbally provided the responsible party with detailed information of the incident on 10/30, however a written report has not been provided to R1's responsible party as of 11/28/2023. Based on information gathered during the course of the investigation, the Department has sufficient evidence to support the allegation of Facility staff did not follow proper reporting requirements. Therefore, this allegation has been 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 appeal rights discussed and a copy of the report was provided to Administrator.the state’s words, verbatim · CDSS document, Nov 28, 2023 · control 29-AS-20231121120147

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Dec 8, 2023

87211(a)(1)(D) - Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above, as R1's responsible party was not provided a written report of incident that occurred on 10/29, which poses a potential health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Nov 28, 2023

Plan of correction: Licensee agreed to provide R1's responsible party with written report of incident that occurred on 10/29/2023 and review regulation cited and provide a statement of understanding to CCL via email by EOD 12/08/2023.

Allegation investigated: Staff did not adequately supervise residents, resulting in a resident hitting another resident while in care.

Licensing Program Analyst (LPA) Martha Arroyo arrived unannounced to conduct an initial complaint visit for the above allegation. Upon arrival, the LPA met with Executive Director (ED) Sabrina Pegross and Director of Health Services (DHS) Heather Hampel and the reason for the visit was explained. Entrance interview conducted. During today's visit, the LPA along with the ED and DHS conducted a tour of the facility to ensure there are no health and safety concerns at 12:20 p.m., conducted interviews with four staff and five residents between 12:35 p.m. and 2:50 p.m., conducted a file review at 11:45 a.m., and obtained copies of the census, staff schedule, and other pertinent documents relevant to the investigation. (Report Continued on LIC 9099C...) Unsubstantiated (Report Continued from LIC 9099...) Regarding the allegation: Staff did not adequately supervise residents, resulting in a resident hitting another resident while in care. It was reported that Resident #1 (R1) was hit in the head by Resident #2 (R2) and facility staff did not report altercation. Record review revealed the facility had self-reported incident to the Department on 10/30/2023 regarding incident that had occurred on 10/29/2023. Incident report stated that at approximately 8:30 p.m., staff were in the dining room when they heard a loud noise coming from the living room. When staff went to see what was going on, they found R1 and R2 arguing. R1 stated R2 had slapped them on the back of the head. R2 admitted to tapping R1 on the head. Both R1 and R2 were separated, and no further incident or injuries were noted. Additionally, R1 and R2 were roommates before incident; however, after the incident, residents have been moved to separate bedrooms. Information obtained and reviewed revealed R1 was admitted to the facility on 08/29/2023 and R2 was admitted to the facility on 04/08/2023. A review of R1’s physicians report dated 08/30/2023, listed R1’s primary diagnosis as dementia and identified R1 as confused/disoriented; however, is not aggressive and is able to follow instructions and communicate their needs. Additionally, a review of R2’s physicians report dated 02/06/2023, listed R2’s primary diagnosis as dementia and type 2 diabetes and identified R2 as confused/disoriented with no inappropriate or aggressive behaviors. Interviews conducted with staff revealed prior to this incident, there had not been other incidents that involved R1 and R2. Staff stated R1 had forgotten about the incident occurring shortly as well. Interview conducted with a family member revealed that they have not had any issues with the supervision facility staff is providing the residents. Interviews with residents revealed there is staff present all around and reported feeling safe. Further interviews revealed five out of five residents did not express any concerns about living at the facility. Based on the information gathered during the course of the investigation, the Department does not have sufficient evidence to support the allegation of ‘staff did not adequately supervise residents, resulting in a resident hitting another resident while in care’. Therefore, this allegation is being deemed Unsubstantiated at this time. Exit interview conducted. No citations issued at this time. A copy of the report was issued.the state’s words, verbatim · CDSS document, Nov 2, 2023 · control 29-AS-20231031082743

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit for the purpose of following up on two (2) self-reported incidents that occurred on 10/25/2023 and 10/29/2023. LPA met with both Director of Health Services Heather Hampel and Administrator Sabrina Pegross. LPA explained the reason for today's visit. Entrance interview conducted. On 10/27/2023 a Suspected Abuse Report was received via e-fax at the Woodland Hills Regional Office. LPA Emily Peraldi reviewed the document, which indicates that on 10/25/2023 staff found Resident #1 (R1) inside Resident #2 (R2)’s room. R1 was observed on the ground and bleeding, R2 had blood on their hands and an unplugged radio was observed nearby. LPA Peraldi called and spoke with Ms. Hampel regarding the report and requested that an Incident Report be submitted to CCLD. Incident report was received later that same day. A second incident report was received on 10/30/2023 related to an incident that occurred between Resident #3 (R3) and Resident #4 (R4) on 10/29/2023. R3 and R4 were observed in the living room area engaged in a verbal altercation. R3 indicated that R4 had hit them, R4 admitted to hitting R3. During today’s visit, LPA toured the facility with both Director of Health Services and Administrator at 09:50AM, reviewed and obtained copies of pertinent documents, took photographs, LPA observed both R1 and R2, and interviewed both managers throughout the visit. Record review revealed that none of the residents involved in either incident have any documented aggressive behavior. Interview related to the incident involving R1 and R2 revealed that when staff found the residents, neither seemed agitated. R1 does tend to wander throughout the secure facility and at times into other resident rooms. R2 tends to keep to themselves and remains in their room most times. Neither R1 nor R2 were able to communicate what had happened inside R2’s room, and the door was shut at the time, so there were no additional witnesses to the incident. The incident occurred before dinner time and staff found both R1 and R2 when assisting residents to the dining room. Documents reviewed did not indicate that either Continued on LIC 809-C resident requires additional supervision. Although R1 did sustain injuries as a result of the incident, R1 returned to the facility the same day. As a result of the incident, the facility has been providing additional supervision for both residents. Documents reviewed for R3 and R4 indicate that there is no previous aggressive behavior for either resident. The residents were roommates at the time of the incident, but as a result of the incident, they are no longer roommates. Interview revealed that R4’s medication has been adjusted as well. Administrator reported that the facility staffing ratio is sufficient at this time. No deficiencies issued at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 31, 2023

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Zabel Chochian conducted a Case Management - Incident visit at the facility today to follow up on incident reports received 10/23/23. The LPA met with Executive Director (ED) Sabrina Pegros and explained the reason for the visit. Following was discussed with the ED from approximately 2:45pm-3:45pm. On 10/23/2024, the Department received a self reported incident from this facility regarding an incident pertaining to staff. On 10/16/23, an associate file audit was conducted by the facility and associate statements pertaining to Staff #1's interaction with residents was discovered. Staff #1 was placed on suspension on 10/17/2023 pending internal investigation by facility. On 10/20/23, staff interviews were conducted at the community with individuals who work with staff #1. There were reports that staff #1 was being forceful with residents when administering medication; alleged abuse and also reports of attitude and demeaning comments made to residents. ED mentioned that calls were placed to former ED Stephanie Funderburg and former Director of Health Services Hope Langston who were employed at the community when the initial reports were made however no response received at this time. Current ED reported that based on their internal investigation staff #1 will not be returning to the community and will officially be terminated as of 10/25/2023. ED stated that they have started In-service on mandated reporting and resident abuse training with staff and will complete in-service with all staff by 10/26/2023. LPA reviewed staff files from 4-5:15pm; LPA gathered copies of record for further review/investigation into the alleged abuse mentioned above. Additional incident reports were discussed with current ED. Two (2) separate incidents regrading client to client aggression was reported to the department. First incident reported occurred on 10/21/2023 in the morning at 8AM - Resident #1 pushed Resident #2's wheelchair and it flipped backwards; resident #2 sustained a skin tear on the left ear; resident #2 was provide immediate medical attention. (cont.to LIC809c) Resident #1 was redirected. Second incident occurred on 10/21/2023 in the evening at approximately 7:45pm - resident #3 swung walker and struck resident #4's head (0.5cm abrasion noted above left eye). According to current ED in both incidents staff was present and redirected residents and immediate medical attention was provided. LPA requested that the incident reports be resubmitted with the additional details. Current ED reported that the staffing ratio is 1:9; there are six (6) caregivers and one (1) charge nurse/med-tech on duty for each shift (AM/PM); private companions are also assigned to some residents requiring one on one. Current ED mentioned that if staff call out they always fill behind any call outs through the staffing agency. Current ED reported that the facility staffing ratio is sufficient at this time. No deficiencies issued at this time. Exit interview conducted. A copy of the report provided.the state’s words, verbatim · CDSS document, Oct 24, 2023