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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200709
Report Date: 10/27/2021
Date Signed: 10/27/2021 04:35:08 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/31/2020 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20201231082804
FACILITY NAME:SILVERADO SENIOR LIVING - BERKELEYFACILITY NUMBER:
019200709
ADMINISTRATOR:SNEE, ROBERT EFACILITY TYPE:
740
ADDRESS:2235 SACRAMENTO STTELEPHONE:
(510) 841-4844
CITY:BERKELEYSTATE: CAZIP CODE:
94702
CAPACITY:0CENSUS: 75DATE:
10/27/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Robert Snee, AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility did not inform authorized representative(s) about residents change of condition in a timely manner.
INVESTIGATION FINDINGS:
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On 10/272021 at 10:30AM, Licensing Program Analysts (LPAs) L. Hall and L. Holmes arrived unannounced to conduct investigation and deliver complaint findings for the above allegation. LPAs met with Robert Snee, Administrator, and explained the reason for the visit.

During the course of the investigation, LPAs conducted interviews with staff and a witness. LPA J. Hamilton conducted interview with Reporting Party (RP), obtained and reviewed documents. Document review indicated that there was an email blast dated 12/19/2020 which stated the facility had positive staff and residents. Per record review there was not any documentation for notifying each Responsible party regarding COVID positive cases and during interview staff stated that a list was given to a leadership person or nursing staff to notify resident's responsible party.

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20201231082804
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SILVERADO SENIOR LIVING - BERKELEY
FACILITY NUMBER: 019200709
VISIT DATE: 10/27/2021
NARRATIVE
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Continued from LIC9099.

Based on LPAs interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 is being cited on the attached LIC9099D.

Exit interview conducted. A copy of appeal rights and this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 15-AS-20201231082804
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SILVERADO SENIOR LIVING - BERKELEY
FACILITY NUMBER: 019200709
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/03/2021
Section Cited
CCR
87468.1(a)(8)
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87468.1 (a)Residents... shall have all of the following personal rights: (8) To have their representatives... informed by the licensee of... care or services... as appropriate to their needs. This requirement was not met as evidence by:
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Administrator agreed to review regulation 87468.1 and submit self-certification to CCLD by POC date.
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Based on LPAs record review Licensee did not comply with the section cited above by notifiy resident's responsible party which poses a potential health and safety risk for persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3