Inspection Reports for Silverado Thousand Oaks Memory Care Community
CA, 91360
Back to Facility ProfileInspection Report Summary
Most inspections found deficiencies related primarily to resident care and supervision, medication management, and staff conduct, with several substantiated complaints involving neglect, inadequate staffing, and failure to protect residents from harm. The facility received a significant civil penalty of $9,500 on September 19, 2025, for a serious injury caused by lack of supervision and delayed medical attention. Other issues included failure to notify responsible parties of changes in condition, inadequate documentation, and a substantiated case of staff abuse resulting in arrest. Several complaint investigations were unsubstantiated, and some recent inspections, including the most recent on October 2, 2025, found no deficiencies, indicating some improvement. The overall pattern shows ongoing challenges with resident care and supervision but also steps toward compliance in the latest reports.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 43
Capacity: 82
Deficiencies: 0
Oct 2, 2025
Visit Reason
The visit was an unannounced Case Management – Incident inspection triggered by a self-reported incident and subsequent death report of Resident #1 on 2025-09-15.
Findings
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.
Complaint Details
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.
Report Facts
Facility capacity: 82
Resident census: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robloe Babasanta | Administrator | Met with Licensing Program Analyst during inspection and communicated with family after resident death |
| Heather Hampel | Director of Health Services | Met with Licensing Program Analyst during inspection |
| Kelly Dulek | Licensing Program Analyst | Conducted the unannounced Case Management – Incident visit |
Inspection Report
Follow-Up
Census: 40
Capacity: 82
Deficiencies: 0
Sep 19, 2025
Visit Reason
Unannounced inspection to follow up on a substantiated allegation of a complaint investigation regarding lack of care and supervision resulting in a resident fall and delayed medical attention.
Findings
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.
Complaint Details
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.
Report Facts
Civil penalty amount: 9500
Immediate civil penalty amount: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heather Hampel | Director of Health Services | Met with Licensing Program Analyst during inspection and acknowledged receipt of appeal rights |
| Kelly Dulek | Licensing Program Analyst | Conducted the unannounced follow-up inspection |
| Kristin Heffernan | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 82
Deficiencies: 0
Apr 30, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations regarding resident care and staff conduct at Silverado Thousand Oaks, LLC.
Findings
The investigation found insufficient evidence to substantiate any of the allegations, including neglect leading to hospitalization, inadequate incontinence care, rough handling of residents, insufficient food intake, delayed response to calls for assistance, staff yelling at residents, and refusal to provide records. All allegations were deemed unsubstantiated.
Complaint Details
The complaint involved seven allegations concerning resident hospitalization due to urinary tract infection from staff neglect, unmet incontinence care needs, rough handling causing bruising, insufficient food intake, delayed response to calls for assistance, staff yelling at resident, and refusal to provide records to resident’s responsible person. The investigation concluded all allegations were unsubstantiated due to lack of sufficient evidence.
Report Facts
Capacity: 82
Census: 40
Complaint Control Number: 29-AS-20240409091302
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Robloe Babasanta | Administrator | Facility administrator interviewed during the investigation |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 40
Capacity: 82
Deficiencies: 0
Mar 25, 2025
Visit Reason
The inspection was a required one-year unannounced visit to evaluate the facility's compliance with licensing regulations.
Findings
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.
Report Facts
Residents interviewed: 4
Staff interviewed: 5
Resident medication files reviewed: 4
Personnel files reviewed: 5
Water temperature range (degrees F): 114.2-115.2
Fire extinguisher service date: Jul 15, 2024
Fire alarm last inspection date: Jun 10, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robloe Babasanta | Administrator | Met with Licensing Program Analysts during the inspection |
| Quoc Huynh | Licensing Program Analyst | Conducted the inspection and signed the report |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 82
Deficiencies: 3
Mar 25, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 11/05/2024 regarding neglect, lack of care and supervision, failure to provide basic services, failure to reappraise residents, retention of a resident requiring a higher level of care, and inadequate staffing.
Findings
The investigation substantiated multiple allegations including neglect leading to the death of a resident caused by another resident, failure to provide basic services and safety, failure to reappraise residents despite significant behavioral changes, and inadequate staffing with untrained agency staff. The facility failed to protect a vulnerable resident from harm, did not administer prescribed medications, and did not intervene appropriately during dangerous behaviors.
Complaint Details
The complaint was substantiated. It involved neglect and lack of care where Resident 1 caused severe injuries to Resident 2 leading to death. The facility failed to provide basic services, failed to reappraise residents, retained a resident requiring a higher level of care, and had inadequate staffing. The investigation included interviews, document reviews, and coordination with law enforcement.
Severity Breakdown
Type A: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility staff did not keep Resident 2 safe from Resident 1, resulting in Resident 2's death, posing an immediate health and safety risk. | Type A |
| No reappraisal was completed despite significant changes in Resident 1's mental condition and behavioral expressions, posing an immediate health and safety risk. | Type A |
| Facility personnel were insufficient in numbers and not competent to meet resident needs; agency staff (Staff #1) was not trained per regulation, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 82
Census: 40
Civil penalty: 500
Staff scheduled overnight: 3
Agency staff orientation hours: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robloe Babasanta | Administrator | Met with Licensing Program Analysts and involved in investigation |
| Kelly Dulek | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Kristin Heffernan | Licensing Program Manager | Oversaw complaint investigation |
| Phillipe Ryan Miles | Investigator | Investigated incident and reviewed law enforcement reports |
| MaeRetha Coleman | Long Term Care Ombudsman | Assisted in complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 82
Deficiencies: 2
Dec 23, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-09-14 alleging that resident care needs were not met and staff did not initiate meetings with the resident's responsible person, among other allegations.
Findings
The investigation substantiated that the facility failed to meet resident care needs and did not initiate required care plan meetings with the resident's responsible person, resulting in a resident's hospitalization for UTI and pneumonia. Other allegations regarding staff leaving a resident in soiled clothing and unclean rooms were unsubstantiated due to insufficient evidence.
Complaint Details
The complaint investigation was substantiated for allegations that resident care needs were not met and staff failed to initiate meetings with the resident's responsible person. The resident (R1) experienced a decline in condition, was not properly tested for UTI, and was hospitalized with UTI and pneumonia. Other allegations about soiled clothing and room cleanliness were unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The licensee failed to ensure residents are regularly observed for changes in physical, mental, emotional, and social functioning and provide appropriate assistance when unmet needs are revealed. | Type B |
| The licensee failed to arrange required meetings with the resident, responsible person, and appropriate parties to review and revise the care plan upon significant change in condition. | Type B |
Report Facts
Capacity: 82
Census: 46
Deficiencies cited: 2
Plan of Correction Due Date: Dec 27, 2024
Plan of Correction Due Date: Dec 23, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Funderburg | Former Executive Director | Reported to resident's responsible person about planned behavioral mapping and involved in care plan meeting issues |
| Hope Langston | Former Director of Health Services | Informed resident's responsible person that lab never picked up urine sample |
| Zabel Chochian | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Desaree Perera | Licensing Program Manager | Oversaw the complaint investigation and signed the report |
Inspection Report
Census: 49
Capacity: 82
Deficiencies: 0
Nov 1, 2024
Visit Reason
The visit was a Case Management - Incident inspection conducted due to a self-reported incident involving two residents at the facility on 11/01/2024.
Findings
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.
Report Facts
Time of incident: 430
Number of residents involved: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heather Hampel | Director of Health Services | Met with Licensing Program Analyst and involved in incident discussion |
| Robloe Babasanta | Administrator | Reported the incident and communicated with Licensing Program Analyst |
| Kelly Dulek | Licensing Program Analyst | Conducted the Case Management - Incident visit |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 82
Deficiencies: 0
Sep 10, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that staff were sleeping while on working hours during the overnight shift.
Findings
The investigation found insufficient evidence to support the allegation that staff were sleeping during their shifts. Staff interviews and management audits indicated no recent occurrences, and no deficiencies were cited.
Complaint Details
The allegation that staff were sleeping during the overnight shift was unsubstantiated. Management reported prior incidents around January or February leading to termination of two staff members, but no reports or observations of sleeping staff occurred in the last six months.
Report Facts
Facility capacity: 82
Census: 51
Staff terminated: 2
Months without reports: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation |
| Heather Hampel | Director of Health Services | Met with Licensing Program Analyst during the investigation and exit interview |
| Robloe Babasanta | Administrator | Facility administrator mentioned in the report |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Annual Inspection
Census: 49
Capacity: 82
Deficiencies: 0
Aug 23, 2024
Visit Reason
The inspection was an unannounced annual continuation visit combined with a legal non-compliance visit, conducted as part of frequent monitoring following a Non-Compliance Conference held on 10/26/2022.
Findings
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.
Report Facts
Resident files reviewed: 5
Staff files reviewed: 5
Residents' medications reviewed: 5
Staff interviewed: 3
Fire drill last conducted: Jul 16, 2024
Fire extinguisher last serviced: Jul 15, 2024
Annual fire protection inspection date: Jun 10, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robloe Babasanta | Executive Director | Met with Licensing Program Analyst during entrance interview and facility tour |
| Heather Hampel | Director of Health Services | Reviewed medications with Licensing Program Analyst |
| Kelly Dulek | Licensing Program Analyst | Conducted the inspection visit and authored the report |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 82
Deficiencies: 2
May 31, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations of physical abuse and conduct inimical involving Staff #1 and Resident #1, received on 2024-02-28.
Findings
The investigation substantiated that Staff #1 physically and emotionally abused Resident #1 on 2024-02-09, as evidenced by video surveillance, staff interviews, and injury documentation. Staff #1 was arrested and charged with misdemeanor elder abuse and being under the influence of a controlled substance while working at the facility.
Complaint Details
The complaint was substantiated. Resident #1 was physically and emotionally injured by Staff #1, who was arrested and charged with misdemeanor elder abuse and being under the influence of a controlled substance. Staff #1 was terminated by the facility.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| 87468.1 Personal Rights of Residents in All Facilities (a)(3) - Residents shall be free from punishment, humiliation, intimidation, abuse, or other punitive actions. This requirement was not met as evidenced by interviews, records review, and video surveillance showing Staff #1 mistreating Resident #1. | Type A |
| 1569.58(a)(2) Persons prohibited from employment due to conduct inimical to health, morals, welfare, or safety. Staff #1 tested positive for being under the influence of a controlled substance while working, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 82
Census: 46
Immediate civil penalty: 500
Plan of Correction Due Date: Jun 7, 2024
Plan of Correction Due Date: Jun 3, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation and visits |
| Rob Babasanta | Administrator | Met with Licensing Program Analyst during investigation |
| Philippe Ryan Miles | Investigator | Conducted further investigation and interviews |
| Sabrina Pegross | Administrator | Facility administrator named in report header |
Inspection Report
Annual Inspection
Census: 46
Capacity: 82
Deficiencies: 0
Mar 29, 2024
Visit Reason
The inspection was an unannounced required annual visit to ensure the facility's compliance with Title 22 regulations and to check for health and safety hazards.
Findings
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.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rob Babasanta | Executive Director | Met with Licensing Program Analyst during inspection and reported on dining room carpet cleaning schedule. |
| Zabel Chochian | Licensing Program Analyst | Conducted the unannounced required annual visit. |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 82
Deficiencies: 1
Feb 22, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were prohibiting a resident from receiving family phone calls.
Findings
The investigation substantiated that facility staff did not transfer calls to the resident as expected, preventing family members from communicating with the resident. The facility policy allows residents to use two cell phones, but staff failed to ensure timely communication.
Complaint Details
The complaint alleged that staff were prohibiting a resident from receiving family phone calls. The allegation was substantiated based on interviews with family members, the resident, and facility staff. The family reported calls were not transferred and callbacks were not made as expected.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents have access to telephones to make and receive confidential calls, violating personal rights. | Type B |
Report Facts
Capacity: 82
Census: 49
Deficiency count: 1
Plan of Correction Due Date: Mar 8, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Urena | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Kasandra Lopez | Licensing Program Manager | Oversaw the complaint investigation report |
| Sabrina Pegross | Administrator | Facility administrator interviewed regarding the complaint |
| Heather Hampel | Director of Health Services | Met with Licensing Program Analyst during exit interview |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 82
Deficiencies: 0
Feb 14, 2024
Visit Reason
The visit was a subsequent Case Management - Incident inspection regarding a self-reported incident involving alleged rough handling and abuse of a resident by staff on 2024-02-09.
Findings
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.
Complaint Details
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.
Report Facts
Census: 49
Total Capacity: 82
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sabrina Pegross | Administrator | Facility administrator met during the inspection and involved in the incident investigation |
| Teresa Camara | Licensing Program Analyst | Conducted the case management incident visit |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 82
Deficiencies: 0
Feb 12, 2024
Visit Reason
The visit was conducted as a Case Management - Incident investigation regarding a self-reported incident of alleged staff mistreatment of a resident that occurred on 2024-02-09.
Findings
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.
Complaint Details
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.
Report Facts
Facility capacity: 82
Resident census: 49
Incident date: Feb 9, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heather Hampel | Director of Health Services | Met with Licensing Program Analyst during the investigation and provided video evidence |
| Teresa Camara | Licensing Program Analyst | Conducted the Case Management - Incident visit |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 82
Deficiencies: 0
Feb 12, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate the allegation that staff do not provide daily activities for residents.
Findings
The Licensing Program Analyst reviewed activity calendars, observed residents participating in activities, and interviewed the administrator and a resident. The allegation that staff do not provide daily activities was found to be unsubstantiated.
Complaint Details
The complaint alleged that staff do not provide daily activities for residents. After investigation including interviews and record review, the allegation was deemed unsubstantiated.
Report Facts
Capacity: 82
Census: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sabrina Pegross | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Sandra Urena | Licensing Program Analyst | Conducted the complaint investigation |
| Kasandra Lopez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 82
Deficiencies: 0
Dec 19, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not refund fees according to the resident's admission agreement and that staff were billing the resident for services not provided.
Findings
The investigation found insufficient evidence to support the allegations. The resident moved out without providing the required 30-day written notice, and a credit was provided as a courtesy. The allegations were determined to be unsubstantiated, and no deficiencies were cited.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to refund fees per the admission agreement and billing for services not provided. The resident moved out on 10/31/2023 without a written 30-day notice, and a credit of $6,616.77 was provided as a courtesy. The admission agreement required a 30-day written notice for termination, which was not received. The refund policy allowed a partial refund after 61-90 days, but the verbal notice delayed the refund period. Based on evidence, the allegations were unsubstantiated.
Report Facts
Credit amount: 6616.77
Administrative Fee: 10000
Days resident stayed: 63
Refund window days: 61
Refund window days: 90
Refund percentage: 40
Deducted fee: 500
Notice period days: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elsie Campos | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sabrina Pegross | Executive Director | Met with Licensing Program Analyst during investigation |
| Kasandra Lopez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 82
Deficiencies: 1
Nov 28, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate the allegation that facility staff did not follow proper reporting requirements related to an incident involving residents on 10/29/2023.
Findings
The investigation found that although the facility self-reported the incident to the Department on 10/30/2023 and verbally informed the responsible party, a written report requested by the responsible party on 11/17/2023 had not been provided as of 11/28/2023. The allegation was substantiated.
Complaint Details
The complaint alleged that facility staff did not follow proper reporting requirements. The allegation was substantiated based on evidence that a written report was not provided to Resident #1's responsible party despite verbal notifications and a request for the report.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide a written report of an incident that occurred on 10/29/2023 to Resident #1's responsible party, violating reporting requirements. | Type B |
Report Facts
Capacity: 82
Census: 45
Deficiency Type B: 1
Plan of Correction Due Date: Dec 8, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Balisi | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Sabrina Pegross | Administrator | Facility administrator met during the investigation and was provided a copy of the report |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 82
Deficiencies: 0
Nov 2, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not adequately supervise residents, resulting in a resident hitting another resident while in care.
Findings
The investigation found that a resident was hit by another resident, but the facility had self-reported the incident and took corrective actions including separating the residents. Interviews and reviews revealed no prior incidents or evidence of inadequate supervision. The allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged inadequate supervision by staff leading to a resident hitting another resident. The allegation was investigated and found unsubstantiated based on interviews, record reviews, and observations.
Report Facts
Facility capacity: 82
Resident census: 53
Incident date: Oct 29, 2023
Complaint received date: Oct 31, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sabrina Pegross | Administrator / Executive Director | Facility administrator met during investigation |
| Heather Hampel | Director of Health Services | Facility DHS met during investigation |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 50
Capacity: 82
Deficiencies: 0
Oct 31, 2023
Visit Reason
The visit was an unannounced Case Management - Incident inspection to follow up on two self-reported incidents that occurred on 10/25/2023 and 10/29/2023 involving resident altercations and injuries.
Findings
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.
Report Facts
Incident dates: 2
Facility capacity: 82
Resident census: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit |
| Heather Hampel | Director of Health Services | Met with Licensing Program Analyst during visit and involved in incident discussions |
| Sabrina Pegross | Administrator | Met with Licensing Program Analyst during visit and involved in incident discussions |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 82
Deficiencies: 0
Oct 24, 2023
Visit Reason
The visit was a Case Management - Incident visit conducted to follow up on incident reports received on 10/23/2023 regarding alleged staff misconduct and resident incidents.
Findings
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.
Complaint Details
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.
Report Facts
Staffing ratio: 9
Number of caregivers per shift: 6
Number of charge nurse/med-tech per shift: 1
Number of caregivers and charge nurse/med-tech per shift: 7
Number of incidents reported: 2
Date of staff suspension: 17
Date of planned staff termination: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sabrina Pegros | Executive Director | Met with Licensing Program Analyst during the visit and provided information on the investigation and staffing. |
| Zabel Chochian | Licensing Program Analyst | Conducted the Case Management - Incident visit and reviewed staff files. |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Monitoring
Census: 55
Capacity: 82
Deficiencies: 2
Aug 1, 2023
Visit Reason
The visit was an unannounced Case Management / Non-Compliance visit to ensure the facility was maintaining substantial compliance as discussed in a prior Non-Compliance Conference on 10/26/2022, with the licensee placed on frequent monitoring for two years.
Findings
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.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Personal grooming and hygiene items were accessible and unlocked in rooms of two residents with dementia who are at risk if they have access to these items. | Type A |
| Staff training hours and topics could not be verified for five staff members as required by regulation. | Type B |
Report Facts
Confirmed COVID-19 positive cases: 3
Residents with accessible personal care items: 5
Residents at risk with accessible personal care items: 2
Staff files reviewed: 5
Facility capacity: 82
Facility census: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the inspection and authored the report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Supervisor overseeing the inspection |
| Stephanie Funderburg | Administrator | Facility administrator met during inspection |
Inspection Report
Annual Inspection
Census: 54
Capacity: 82
Deficiencies: 2
May 15, 2023
Visit Reason
The visit was an unannounced required annual inspection combined with a case management visit to ensure the facility was maintaining substantial compliance following a Non-Compliance Conference held on 10/26/2022.
Findings
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.
Severity Breakdown
Type A: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| One out of five resident records was missing a signed admissions/residency agreement. | — |
| Failure to document assistance with self-administration of PRN medication for three residents (R1, R2, R3), posing an immediate health and safety risk. | Type A |
Report Facts
Residents reviewed: 5
PRN medication administrations undocumented: 4
Plan of Correction due date: May 18, 2023
Plan of Correction completion date: May 24, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the inspection and authored the report |
| Stephanie Funderburg | Executive Director | Met with Licensing Program Analyst during the inspection |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Annual Inspection
Census: 48
Capacity: 82
Deficiencies: 2
Feb 6, 2023
Visit Reason
The inspection was an unannounced required annual visit to ensure the facility was maintaining substantial compliance following a Non-Compliance Conference held on 10/26/2022, with the licensee placed on frequent monitoring for two years.
Findings
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.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Three out of seven staff had fingerprint clearance but were not associated to this location, posing an immediate health and safety risk. | Type A |
| Trash observed in the first and second floor bistro and downstairs courtyard, and cushions on the second floor balcony were unclean, posing a potential health and safety risk. | Type B |
Report Facts
Staff files reviewed: 7
Staff with fingerprint clearance not associated: 3
Civil penalty amount: 500
Capacity: 82
Census: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the inspection and authored the report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Supervisor overseeing the inspection |
| Stephanie Funderburg | Administrator | Facility administrator involved in plan of correction |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 82
Deficiencies: 1
Sep 14, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 04/04/2022 regarding staff failure to report a change of condition to Resident #1's responsible party and other allegations.
Findings
The investigation substantiated that staff failed to notify Resident #1's responsible party of the resident's refusal and discontinuation of medications, posing an immediate health and safety risk. Other allegations regarding failure to assist with medication self-administration, safeguarding personal property, and meeting hygiene needs were found unsubstantiated.
Complaint Details
The complaint investigation was substantiated regarding staff failing to report Resident #1's refusal of medications and discontinuation to the responsible party. Other allegations about medication assistance, safeguarding personal property, and hygiene needs were unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify Resident #1's responsible party of changes in condition related to medication refusal, violating CCR 87466. | Type A |
Report Facts
Facility capacity: 82
Census: 55
Deficiency count: 1
Plan of Correction due date: Sep 16, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation |
| Ronda Wilkin | Executive Director | Facility administrator met during the investigation and named in findings |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 82
Deficiencies: 0
Sep 7, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that the facility failed to have planned activities and did not follow the scheduled program of activities as planned.
Findings
The investigation found that the facility did have daily activities, although schedules sometimes changed based on resident interest and vendor availability. Staff encouraged resident participation, and there was insufficient evidence to support the allegation. The complaint was deemed unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint alleged that the facility failed to have planned activities and did not follow the scheduled program. The allegation was unsubstantiated based on staff interviews, observations, and document review.
Report Facts
Facility capacity: 82
Resident census: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 82
Deficiencies: 1
Aug 3, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that a resident attained unsecured medications resulting in hospitalization and death, and that the licensee failed to comply with reporting requirements.
Findings
The investigation found insufficient evidence to support claims that the resident attained unsecured medications leading to hospitalization or death, deeming those allegations unsubstantiated. However, the licensee was found to have failed to submit required incident reports for several hospitalizations, substantiating the reporting requirements violation.
Complaint Details
The complaint alleged that Resident #1 obtained unsecured medications resulting in hospitalization and death, and that the licensee failed to fulfill reporting requirements. The medication-related allegations were unsubstantiated, but the reporting failure was substantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit incident reports for all hospitalizations of Resident #1, posing a potential health and safety risk. | Type B |
Report Facts
Capacity: 82
Census: 49
Deficiency count: 1
Plan of Correction due date: Aug 8, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and issued findings |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation report |
| Ronda Wilkin | Executive Director | Facility representative met during the investigation |
Inspection Report
Annual Inspection
Census: 43
Capacity: 82
Deficiencies: 4
Feb 28, 2022
Visit Reason
The inspection was a required one-year post licensing visit conducted unannounced to evaluate compliance with Title 22 regulations and ensure health and safety standards at the facility.
Findings
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.
Severity Breakdown
Type A: 2
Type B: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to assist residents with self-administered medications as needed, specifically medication errors and lack of documentation for PRN medication for one resident (R2). | Type A |
| Failure to maintain a record of each dose of PRN medication including date, time, dosage, and resident response for one resident (R2). | Type A |
| Missing medical assessment documentation for one out of five resident files (R1). | Type B |
| Missing health screenings for two out of five staff records (S1, S2). | Type B |
Report Facts
Residents files reviewed: 5
Staff files reviewed: 5
Medication pills administered: 9
Medication pills total: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the inspection and authored the report |
| Ronda Wilkin | Executive Director | Facility representative met during inspection |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 82
Deficiencies: 2
Feb 16, 2022
Visit Reason
The inspection visit was conducted as a complaint investigation following allegations that a resident suffered a fall due to lack of care and supervision and that the facility did not seek medical attention in a timely manner.
Findings
The investigation substantiated that due to lack of supervision, Resident #1 suffered a fall resulting in multiple injuries including rib fractures. It was also substantiated that the facility failed to seek timely medical attention after the fall. Another allegation that the resident was left in soiled clothing was unsubstantiated.
Complaint Details
The complaint investigation was substantiated regarding lack of supervision leading to a resident fall with injuries and failure to seek timely medical attention. The allegation that the resident was left in soiled clothing was unsubstantiated.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision resulting in resident fall and injuries. | Type A |
| Failure to ensure timely medical attention following resident's fall. | Type A |
Report Facts
Civil penalty amount: 500
Capacity: 82
Census: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report. |
| Ronda Wilkin | Executive Director | Met with Licensing Program Analyst during the investigation. |
| Dennis Seng | Investigator | Assigned to the complaint investigation case and reviewed evidence. |
Inspection Report
Census: 33
Capacity: 82
Deficiencies: 0
Aug 6, 2021
Visit Reason
The visit was a technical support visit with a specific emphasis on infection control practices.
Findings
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.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Arrived at 8am to conduct the technical support visit focused on infection control. |
| Ronda Wilkin | Executive Director | Met with Licensing Program Analyst during the visit. |
| Amanda Ball | Public Health Nurse | Attended the visit from Ventura County Public Health. |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 17
Capacity: 82
Deficiencies: 2
May 5, 2021
Visit Reason
The visit was an unannounced Case Management - Incident inspection to follow up on an elopement incident involving Resident #1 that occurred on 2021-04-25.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The egress connection for the service door was inoperable, allowing Resident #1 to leave the facility without triggering an alarm, posing an immediate health and safety risk. | Type A |
| The facility failed to ensure that all exits were secure to prevent elopements, posing an immediate health and safety risk to residents in care. | Type A |
Report Facts
Deficiencies cited: 2
Plan of Correction Due Date: May 6, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ronda Wilkin | Executive Director | Met with Licensing Program Analysts during the visit and reported the elopement incident. |
| Ashley Smith | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Sandra Urena | Licensing Program Analyst | Conducted the inspection. |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Supervisor of the inspection. |
Inspection Report
Original Licensing
Capacity: 82
Deficiencies: 0
Mar 5, 2021
Visit Reason
The visit was an announced prelicensing inspection to evaluate the facility prior to licensing approval.
Findings
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.
Report Facts
Maximum bedridden resident capacity: 12
Hospice waiver capacity: 25
Number of resident units: 47
Water temperature range (degrees Fahrenheit): 111-116
Food delivery frequency: 2
Emergency food supply duration (days): 7
Fire extinguisher purchase date: May 12, 2020
Fire department final inspection dates: 2
Facility elevators: 2
Facility stairwells: 2
Passenger bus seating capacity: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ronda Wilkin | Executive Director | Met with Licensing Program Analyst during prelicensing inspection. |
| Jason Russo | Regional Administrator | Met with Licensing Program Analyst during prelicensing inspection. |
| Ashley Smith | Licensing Program Analyst | Conducted the prelicensing inspection and authored the report. |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in the report as Licensing Program Manager. |
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