Silverado Thousand Oaks, Llc.

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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.

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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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 2 nd 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.

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.

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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.

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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.

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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 There are three outdoor gated courtyards; two are on the first floor and one is on the 2 nd 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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.

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.

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.

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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.

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.

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.

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 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.

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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.

(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.

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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.

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) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.