019200709-11-18-2021-15-AS-KHOS-C9CNUQ-20211203094643

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200709
Report Date: 11/18/2021
Date Signed: 11/18/2021 10:22:44 AM

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
02/01/2021 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20210201084114

FACILITY NAME:	SILVERADO SENIOR LIVING - BERKELEY		FACILITY NUMBER:	019200709
ADMINISTRATOR:	SNEE, ROBERT E		FACILITY TYPE:	740
ADDRESS:	2235 SACRAMENTO ST		TELEPHONE:	(510) 841-4844
CITY:	BERKELEY	STATE: CA	ZIP CODE:	94702
CAPACITY:	0	CENSUS: 75	DATE:	11/18/2021
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Robert Snee, Administrator		TIME COMPLETED:	10:25 AM

ALLEGATION(S):

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Facility failed to provide adequate care and supervision resulting in resident developing a pressure sore.

Facility failed to provide timely notification for resident's change in condition.

INVESTIGATION FINDINGS:

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On 11/18/2021 at 09:45 AM, Licensing Program Analysts (LPAs), L. Hall and Jill Clancy-Czuleger arrived unannounced to deliver complaint findings for the above allegations. LPAs met with Robert Snee, Administrator and explained the reason for the visit.

During the course of the investigation, LPA J. Hamilton interviewed staff, witness, Reporting Party (RP), obtained and reviewed documents. Based on the Department’s investigation regarding the allegation the facility staff failed to provide adequate care and supervision resulting in resident developing a pressure sore. LPA reviewed staff schedules and case notes which indicated R1 received frequent checks. Due to facility being on isolation due to the COVID outbreak R1 was not able to move about common areas as normal.

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20210201084114

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: 11/18/2021

NARRATIVE

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Continued from LIC9099.

On the allegation facility failed to provide timely notification for resident’s change in condition. LPA reviewed case notes and telephone/fax order, both dated 01/22/2021, which indicated R1’s doctor and RP was notified and aware of R1’s condition. Case notes also indicated that RP was notified again on 01/25/2021.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has not been met, therefore the allegation is found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it did or did not occur.

Exit interview conducted and a copy of report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021

LIC9099 (FAS) - (06/04)

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