019200938-9-30-2022-15-AS-YFLS-CKBVXF-20221018164929

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200938
Report Date: 09/30/2022
Date Signed: 09/30/2022 04:09:34 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
04/05/2022 and conducted by Evaluator Lisha Holmes

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220405082146

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: 76	DATE:	09/30/2022
		UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Jeff Emoruwa, Director of Health Services		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

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Resident sustained injury

Lack of supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an investigation for the above allegations. LPA met with Jeff Emoruwa, Director of Health Services.

During the initial 10-day visit on 04/21/22, LPA L. Hall interviewed staff and collected the following documents: staff roster, facility roster, physician report; ID and emergency information, comprehensive assessment and service plan, care conference sheet, and telephone/fax order.

Record of an incident report dated 02/25/22 show that Resident (R1)’s middle finger on the left hand was smashed between the bathroom door at the front lobby. LPA L. Holmes interviewed S5 and S3; based on interviews and record reviews, Staff #6 (S6) had just passed R1 in the hallway that afternoon. S6 went to use the lobby bathroom for him/herself. S2 was working at the front desk, and S3 had just arrived from the activity area and saw R1 walking the hallways while grazing the walls. R1 had trailed S6 as he/she was entering the bathroom. S2 noticed R1 pulling at his/her finger while smashed at the door. S2 yelled out for help to S3.
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: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

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-20220405082146

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: 09/30/2022

NARRATIVE

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...continued from LIC9099

S2 and S3 both began knocking on the bathroom door advising R1 not to pull at finger. S6 heard the knocking and opened the door. Since S2 was working at the front desk, S4 was called to takeover. S4 observed R1’s finger was bluish in color. S4 applied ice, elevated and immobilized left hand, and noted R1 was in pain. S4 called 911, notified POA and PMD. R1 went to the emergency room and was treated for a contusion on the left middle finger with no new orders. Facility doctor assessed R1 upon return and prescribed Tylenol 500 mg every 4 hours for pain management. Based on R1’s Comprehensive and Assessment Plan dated 01/06/2022, no 1:1 care was needed. Interviews with S3 and S5 further revealed that R1 is verbal, and on 03/03/22 R1’s Responsible Party, S1 and the Director of Resident and Family Services (DRFS) met regarding the care and monitoring of R1. S1 agreed that the facility staff will remind, redirect and cue R1 every two hours as needed. S1 will also provide nursing notes to the family as incidents arise

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

Exit interview conducted. A copy of this report provided to Jeff Emoruwa,

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

LIC9099 (FAS) - (06/04)

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