Inspection Reports for
Silverado Thousand Oaks Memory Care Community

The facility was found to be in compliance with health and safety regulations, with no deficiencies cited. Common areas, resident rooms, outdoor areas, kitchen, records, medication storage, infection control, and emergency disaster plans were all inspected and found satisfactory.

The visit was complaint-related due to a self-reported incident and death of Resident #1. The death was determined natural with no citations issued. Further investigation may occur if warranted.

The inspection found that Resident #1 experienced chest pain and collapsed while walking with staff, received CPR from staff and paramedics, but was pronounced deceased. The cause of death was cardiac tamponade secondary to ruptured aortic aneurysm and was listed as natural. No citations were issued during this visit.

The complaint investigation substantiated allegations that due to lack of care and supervision, a resident suffered a fall causing injuries, and the facility did not seek timely medical attention. The licensee was cited for violations of CCR 87468.2(a)(4) and 87465(g). An immediate civil penalty of $500 was issued on February 16, 2022, and an additional civil penalty of $9,500 was issued on September 19, 2025.

The Department concluded that the facility failed to provide proper care and supervision, resulting in a resident sustaining serious bodily injury including rib fractures and hematomas requiring hospitalization. A civil penalty of $9,500 was issued for this serious bodily injury violation.

The facility was found to be in compliance with health, safety, and licensing regulations. No deficiencies were cited during the inspection, and the facility was observed to be clean, safe, and well-maintained with proper documentation and emergency plans in place.

The inspection found no immediate health and safety hazards during the facility tour. The incident involved one resident found agitated with blood on their body and another resident injured and subsequently pronounced deceased. The incident was referred to the Community Care Licensing Division's Investigations Branch for further investigation. No deficiencies were cited during this visit.

The facility was found to be in compliance with Title 22 regulations, with no health or safety hazards observed. Resident and staff files were complete and compliant. The infection control and emergency disaster plans were adequate and up to date. Medication storage and documentation for reviewed residents were compliant. No citations were issued during this visit.

The facility was found to be clean, well-maintained, and in compliance with health and safety regulations. No health or safety hazards were observed, and common areas, kitchen, bedrooms, and restrooms were all in good condition. The annual inspection will be completed on a follow-up visit due to time constraints.

The complaint involved Staff 1 allegedly handling Resident 1 roughly, including slapping, grabbing by the neck and shoulder, verbal threats, and pushing. The Ventura County Sheriff's Office was called and Staff 1 was arrested.

During the visit, interviews were conducted with staff and the facility administrator. No deficiencies were observed at the time of the inspection. The facility is working to obtain video evidence of the incident to forward to authorities.

The complaint involved Staff 1 allegedly handling Resident 1 roughly, slapping, grabbing by the neck and shoulder, verbally threatening, and pushing the resident. The Ventura County Sheriff's Office was called and arrested the staff member. The incident was partially captured on video.

During the visit, the Licensing Program Analyst met with the Director of Health Services, reviewed records, toured the facility, and attempted to interview the resident. Video evidence of the incident was reviewed. No deficiencies were observed during this visit, and the investigation will continue with a follow-up visit.

The investigation found that Resident #1 sustained injuries but returned the same day, and additional supervision was provided for involved residents. No documented aggressive behavior was found for the residents involved, and no deficiencies were issued. The facility staffing ratio was reported as sufficient.

The complaint involved allegations of staff abuse and inappropriate behavior by Staff #1, which was substantiated by the facility's internal investigation resulting in suspension and planned termination. Additional incidents of resident-to-resident aggression were also reported and investigated.

The investigation revealed allegations of staff being forceful with residents during medication administration and making demeaning comments, leading to the suspension and pending termination of Staff #1. Two separate resident-to-resident aggression incidents were reported, with immediate medical attention provided. No deficiencies were issued at this time.

The facility was toured and found generally clean and in good repair with no health or safety hazards observed. However, deficiencies were noted including personal care and hygiene items being accessible and unlocked in rooms of two residents deemed at risk, and inability to verify required staff training hours and topics for five staff members. Additionally, three confirmed COVID-19 cases were reported.

The inspection found one resident file missing a signed admissions/residency agreement and deficiencies related to incomplete documentation of assistance with PRN medications for three residents, posing an immediate health and safety risk.

The facility had some cleanliness issues in common areas such as trash and unclean cushions, and three staff members had fingerprint clearances not associated with this location, posing an immediate health and safety risk. Kitchen appliances and resident rooms were in good condition, and infection control measures were observed to be adequate.

The facility was generally found to be clean, safe, and in compliance with regulations in areas such as physical plant, kitchen, and resident rooms. However, deficiencies were cited related to medication administration documentation, missing medical assessments for one resident, and incomplete health screenings for two staff members.

The facility demonstrated appropriate infection control measures including symptom screening, mask-wearing, hand sanitizer availability, and visitation protocols. No health and safety hazards were noted, though recommendations were made for additional staff training on PPE use and posting signage for physical distancing and hand hygiene.

The visit was triggered by a complaint related to an elopement incident reported by the Executive Director on 2021-04-26 involving Resident #1 who exited the facility through a service door without triggering an alarm.

The facility failed to ensure that the egress connection for the service door was operable, allowing Resident #1 to exit without triggering an alarm, posing an immediate health and safety risk. The egress connection was repaired the following day, and in-service training on elopement protocols was conducted.

The facility was found to be in compliance with applicable regulations, including physical plant conditions, safety systems, medication storage, kitchen operations, and resident room accommodations. The facility is not yet operational and has a maximum capacity of 82 residents with specific limits on bedridden residents.