019200938-8-21-2023-15-AS-YFLS-CUZNDR-20230824102245

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200938
Report Date: 08/21/2023
Date Signed: 08/21/2023 02:05:04 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
04/03/2023 and conducted by Evaluator Lisha Holmes

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230403161244

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:	11:05 AM
MET WITH:	Jeff Emoruwa, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility staff did not ensure that resident's oxygen canister was full.
Facility staff did not implement resident's doctor's orders.
Facility staff did not administer resident new prescription medications timely.

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.

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-20230403161244

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

UNSUBSTANTIATED:
Facility staff did not ensure that resident's oxygen canister was full.
Facility staff did not implement resident's doctor's orders.
Facility staff did not administer resident new prescription medications timely.

For the allegation, facility staff did not ensure that resident's oxygen canister was full. LPA interview S1 and S2 that both stated R1 received oxygen from a concentrator and canister daily. On 03/31/23, R1 was in the common area when W5 arrived who stated that R1’s Oxygen Saturation (SO2) was about 70% which was unacceptable and life threatening. LPA asked were the paramedic’s contacted; W5 stated, “No, I happen to catch it in time” W5 did not provide LPA with any documentation for R1’s OS and said that R1 would be moving after the incident. S1 provided LPA with R1’s Service Plan Details, charted eMar and Vital Signs Trends Report for R1’s SO2. R1’s SO2 remained constant on 03/31/23; at 6:22 AM 96% was recorded, at 1:26 PM 96% was recorded, and at 9:03 PM 97% was recorded. W5 did not provide any documentation of R1’s SO2 levels. On 03/31/23, S2 provided R1 with a replacement cannister and S1 stated that it would be impossible for R1 to walk or breathe if R1’s SO2 was at 70%. Records reviewed revealed that R1’s doctor’s orders were being followed. Oxygentank, R1's SO2 distributor, delivered twelve (12) canisters on 03/02/23 and twelve (12) on 03/16/23. W1 did not return LPA’s phone calls prior, during or after the investigation on 05/01/2023 to confirm R1’s new prescription that was alleged to not being administered.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are 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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