019200938-8-21-2023-15-AS-YFLS-CUZNFU-20230824102608

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200938
Report Date: 08/21/2023
Date Signed: 08/21/2023 01:32:13 PM

Unsubstantiated

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
04/27/2023 and conducted by Evaluator Lisha Holmes

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230427160258

FACILITY NAME:	SILVERADO SENIOR LIVING-BERKELEY		FACILITY NUMBER:	019200938
ADMINISTRATOR:	SNEE, ROBERT		FACILITY TYPE:	740
ADDRESS:	2235 SACRAMENTO STREET		TELEPHONE:	(949) 240-7200
CITY:	BERKELEY	STATE: CA	ZIP CODE:	94702
CAPACITY:	90	CENSUS: 77	DATE:	08/21/2023
		UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Jeff Emoruwa, Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility did not provide information to family where resident moved.

INVESTIGATION FINDINGS:

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On 08/21/23 at 10:05 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the finding and complete the investigation for the above allegation. LPA met with Jeff Emoruwa, Administrator (ADM), and explained the purpose for the visit.

During the investigation, LPA interviewed two (2) Staff (S1, S2), two Witnesses (W2, W5), and requested the following documents: facility roster, R1’s physician report, ID and emergency information, comprehensive assessment and service plan, care notes, Medication Administration Record (MAR), Admission Agreement, and Power of Attorney and/or Conservator documents for R1.

Allegation: The facility did not provide information to family where resident moved.
Unsubstantiated

continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2023

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-20230427160258

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: 019200938
	VISIT DATE: 08/21/2023

NARRATIVE

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...continued from LIC9099

LPA reviewed records and interviewed S1, S2, W2, and W5 which revealed that W1 is the Fiduciary and Responsible Party for R1. W2 stated that W1 refused to give him/her information about R1. S1 stated that W1 did not give notice that R1 was moving; W1 had an issue with W2 and did not want W2 to be allowed to visit although the facility had not had any problems with W2. W5 alleged that there had been emotional, medical, and financial abuse along with the death threats toward R1 from W2. S2 stated that he/she did not have knowledge of R1’s whereabouts and W1 just started gathering things to move R1 on 04/07/23. W1 did not return LPA’s phone calls prior, during or after the investigation on 05/01/2023. To date, W1 did not send any additional notification to S1 regarding R1's relocation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview and a copy of this report provided to ADM.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2023

LIC9099 (FAS) - (06/04)

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