019200938-4-17-2024-15-AS-KHOS-D4MNZN-20240424105438

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200938
Report Date: 04/17/2024
Date Signed: 04/17/2024 11:29:00 AM

Substantiated

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
01/22/2024 and conducted by Evaluator Luisa Fontanilla

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240122165538

FACILITY NAME:	SILVERADO SENIOR LIVING-BERKELEY		FACILITY NUMBER:	019200938
ADMINISTRATOR:	EMORUWA, JEFFREY O		FACILITY TYPE:	740
ADDRESS:	2235 SACRAMENTO STREET		TELEPHONE:	(949) 240-7200
CITY:	BERKELEY	STATE: CA	ZIP CODE:	94702
CAPACITY:	90	CENSUS: 79	DATE:	04/17/2024
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Jeffrey Emoruwa		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Facility staff did not provide adequate supervision resulting in a resident eloping from the facility.
Facility staff disclosed resident's personal information in the presence of others at the facility.

INVESTIGATION FINDINGS:

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On this day at around 10:15 am,, Licensing Program Analyst (LPA Luisa Fontanilla arrived unannounced to deliver findings on the above allegations and met with Jeffrey Emoruwa. LPA explained to Emoruwa the purpose of the visit.

On 1/30/2024, LPA initiated the 10-day investigation and interviewed Staff 1 (S1) and Staff 2 (S2) via zoom due to the facility’s covid outbreak status.

Based on interviews conducted, both S1 and S2 confirmed with LPA that on 1/2/2024, Resident 1 (R1) wandered off the facility without staff knowledge. The alarm went off but the staff who responded to the door failed to see R1 exit the facility. R1 was observed outside the facility by one of the caregivers who finished the shift. R1 was brought back to the facility without any injury. R1 has Dementia and is not able to leave the facility unassisted.
continuation on Lic 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

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-20240122165538

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: 04/17/2024

NARRATIVE

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After the incident, R1’s wife requested a meeting with S1 and S2 together with two other individuals who are not related to R1 but have family members living at the facility. During the meeting, plans and procedures were discussed on how to make sure that R1 is safe while living at the facility. And part of the agenda was to discuss R1’s medications.

Based on interviews conducted, S2 states that it was an oversight on the part of the facility to allow other individuals who are not involved in R1’s care to be part of the meeting since the purpose of the meeting is to address R1's condition and there is always a possibility of disclosing R1’s personal information.

Based on interviews and records reviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are substantiated. California Code of Regulations, Title 22 are being cited on the attached Lic 9099D.

Exit interview was conducted with Emoruwa and Appeal Rights was provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240122165538

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/17/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/17/2024 Section Cited HSC 1569.312	1 2 3 4 5 6 7	H&S §1569.312 (a) Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. -This requirement is not met as evidenced by: Based on interviews and record reviews conducted, R1 who has dementia and is unable to leave facility unassisted wandered off the facility without staff knowledge which poses a potential risk to the health and safety of clients under care. R1 was returned to the facility without any injury.	1 2 3 4 5 6 7	The Administrator has conducted training with staff on 1/9/2024 and provided CCL proof of training. In addition, the Administrator states that actual head counts are being conducted 3x a day in addition to the head counts being conducted by individual caregivers. The Administrator will send additional health and safety plans
	8 9 10 11 12 13 14		8 9 10 11 12 13 14	to CCL to ensure health and safety of residents by 4/30/2024.
Request Denied Type B 04/30/2024 Section Cited CCR 87468.2(a)(2)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (2) To have their records and personal information remain confidential and to approve their release, except as authorized by law.	1 2 3 4 5 6 7	The Administrator states have been advised not to disclose any information to anyone who is not directly responsible for the care of the resident.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews conducted, R1’s medication information was disclosed during the meeting held with R1’s wife and 2 other individuals.	8 9 10 11 12 13 14

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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC9099 (FAS) - (06/04)

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