019200938-3-23-2023-15-AS-KHOS-CQJMC3-20230403092851

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200938
Report Date: 03/23/2023
Date Signed: 03/23/2023 07:01:42 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
11/24/2021 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20211124153927

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: 73	DATE:	03/23/2023
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Jeff Emoruwa/Executive Director		TIME COMPLETED:	07:00 PM

ALLEGATION(S):

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Resident (R1) pushed another resident (R2) while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegation.. LPA met with Jeff Emoruwa, administrator, and informed the reason for visit.

During the course if investigation, LPA reviewed residents' (R1 and R2) records and interviewed staff. LPA obtained copies of staff schedule and the following R1 and R2's documents: LIC601 Identification and Emergency Information; Physician's Reports; Appraisal; SOC341; inter-facility reporting of incident. LPA also reviewed the Unusual Incident Report (UIR)

UIR indicated that on 10/29/21 at approximately 6:30 am, R1 who has dementia, pushed R2 away from R1. Prior to pushing incident, the front desk person (S4) witnessed R2 snatched a newspaper from R1 which triggered the behavior. S4 separated R1 and R2, and contacted the nurse for assessment. Review of records showed R1 and R2 have dementia.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

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-20211124153927

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: 03/23/2023

NARRATIVE

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On 12/02/21, LPA interviewed Jeff Emoruwa, previous Executive Director Robert Snee and staff (S2 and S3). Jeff Emoruwa stated he was not at the facility when the incident between R1 and R2 happened but it was reported to him. Robert Snee stated he was at the facility that early morning but he did not witnessed when it was happening. Snee indicated it the first time R1 exhibited aggressive behavior. S2 stated she did not witnessed the incident but the front desk person (S4) who witnessed it called, and she and the facility LVN went to the lobby where the incident took place. They separated the residents. S2 stated R1 is a nice person and it was the first time R1 exhibited aggressive behavior. Staff were told to monitor R1 and R2. S3 indicated she did not witness the incident, and R1 and R2 were not assigned to her. LPA was not able to obtain information from R1, R2 and S4.

On this day, 3/23/23, LPA interviewed S1 and S5. S1 stated he does not remember exactly what happened but with residents with diagnosis of dementia, incident can happen so fast, and when it happens, they separate the residents. He assess and determines what are the triggers to the behavior. If there's injury, they call 9-1-1 and notify the resident's primary care physician and responsible person. S5 stated when incident between residents happen, they separate the residents and call the facility LVN to assess. If there's injury, they call 9-11 right away.

Based on all information gathered, and LPA unable to obtain information from R1, R2 and S4, the allegation of resident (R1) pushed another resident (R2) while in care is closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No citation issued.

Exit interview conducted, and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC9099 (FAS) - (06/04)

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