Inspection Reports for Silverado Thousand Oaks Memory Care Community

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.

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 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.

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.

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 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.

An unannounced complaint investigation visit was conducted in response to multiple allegations regarding resident care and staff conduct at Silverado Thousand Oaks, LLC.

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.

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.

The inspection was a required one-year unannounced visit to evaluate the facility's compliance with licensing regulations.

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 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.

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.

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.

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.

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.

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.

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.

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 visit was an unannounced complaint investigation conducted in response to an allegation that staff were sleeping while on working hours during the overnight shift.

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.

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.

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.

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 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.

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.

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.

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.

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 inspection was an unannounced complaint investigation visit triggered by an allegation that staff were prohibiting a resident from receiving family phone calls.

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.

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.

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.

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, 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.

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.

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 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.

The inspection was an unannounced complaint investigation visit conducted to investigate the allegation that staff do not provide daily activities for residents.

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.

The complaint alleged that staff do not provide daily activities for residents. After investigation including interviews and record review, the allegation was deemed unsubstantiated.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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 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.

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 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 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.

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 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.

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 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.

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 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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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 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.

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.

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.

The visit was a technical support visit with a specific emphasis on infection control practices.

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 an unannounced Case Management - Incident inspection to follow up on an elopement incident involving Resident #1 that occurred on 2021-04-25.

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 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 visit was an announced prelicensing inspection to evaluate the facility prior to licensing approval.

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.