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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608179
Report Date: 04/01/2021
Date Signed: 04/07/2021 11:16:11 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/05/2021 and conducted by Evaluator Jennifer Jones
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210105162254
FACILITY NAME:SILVERADO SENIOR LIVING - BEACH CITIESFACILITY NUMBER:
197608179
ADMINISTRATOR:DAIZEL GASPERIANFACILITY TYPE:
740
ADDRESS:514 N PROSPECT AVETELEPHONE:
(310) 896-3100
CITY:REDONDO BEACHSTATE: CAZIP CODE:
90277
CAPACITY:120CENSUS: 56DATE:
04/01/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Daizel Gasperian, administrtor TIME COMPLETED:
02:47 PM
ALLEGATION(S):
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Staff administered medication to resident without physician's order.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jennifer Jones initiated a complaint investigaResident sustained unexplained injuries while in care.tion and delivered findings for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with facility administrator

On 01/15/21, LPA Cardenas interviewed administrator, Daizel Gasperian and explained the purpose of todays contact. A tele-visit tour of facility was conducted with Director of Health Services, Deliza Iglesias. LPA requested that a copy of resident/ staff roaster is emailed to LPA Cardenas.

On 04/05/21 and 04/01/21 LPA Jones interviewed staff 1-6 and on 04/02/21 LPA Jones interviewed residents 1-5.

On 04/05/21, LPA Jones delivered findings to Daizel Gasperian. The allegation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jennifer JonesTELEPHONE: (323) 516-3833
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 11-AS-20210105162254
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SILVERADO SENIOR LIVING - BEACH CITIES
FACILITY NUMBER: 197608179
VISIT DATE: 04/01/2021
NARRATIVE
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For allegation (Staff administered medication to resident without physician's order) It was alleged that a staff member administered 5 tablets of 5mg Melatonin to a resident without a physician's order. During the interviews conducted with staff, some of the staff revealed that they heard about the incident that took place but did not witness it. Staff 5 stated that she was working on the day the incident took place and reported it after the incident happened. Staff 8 admitted to the allegation and stated that he contacted the resident's doctor for a PRN after he administered the medication to the resident. The administrator revealed during her interview that she was informed about the incident and confirmed that it did happen. The administrator stated that staff 8 was retrained as a result from the incident. The administrator stated that she did not have or submit an incident report about the incident.

Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D.

A telephonic exit interview was conducted with Administrator and a copy of this report was provided via email for signature.
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jennifer JonesTELEPHONE: (323) 516-3833
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/05/2021 and conducted by Evaluator Jennifer Jones
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210105162254

FACILITY NAME:SILVERADO SENIOR LIVING - BEACH CITIESFACILITY NUMBER:
197608179
ADMINISTRATOR:DAIZEL GASPERIANFACILITY TYPE:
740
ADDRESS:514 N PROSPECT AVETELEPHONE:
(310) 896-3100
CITY:REDONDO BEACHSTATE: CAZIP CODE:
90277
CAPACITY:120CENSUS: 57DATE:
04/01/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Daizel Gasperian, administrtor TIME COMPLETED:
02:47 PM
ALLEGATION(S):
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Resident sustained unexplained injuries while in care.
Staff handle residents roughly
Staff did not properly dispose of soiled diapers.
Staff not speaking to residents respectfully.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jennifer Jones initiated a complaint investigaResident sustained unexplained injuries while in care.tion and delivered findings for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with facility administrator

On 01/15/21, LPA Cardenas interviewed administrator, Daizel Gasperian and explained the purpose of todays contact. A tele-visit tour of facility was conducted with Director of Health Services, Deliza Iglesias. LPA requested that a copy of resident/ staff roaster is emailed to LPA Cardenas.

On 03/29/21 and 04/01/21 LPA Jones interviewed staff 1-6 and on 04/02/21 LPA Jones interviewed residents 1-5.

On 04/05/21, LPA Jones delivered findings to Daizel Gasperian. The allegation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jennifer JonesTELEPHONE: (323) 516-3833
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20210105162254
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SILVERADO SENIOR LIVING - BEACH CITIES
FACILITY NUMBER: 197608179
VISIT DATE: 04/01/2021
NARRATIVE
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For allegation (Resident sustained unexplained injuries while in care.) It was alleged that a resident was found on his bedroom floor with dark bruises on his outer and inner thighs and scrapes on his shoulder. It is also being alleged that the resident was abused about a staff member. The administrator revealed during her interview that all staff conduct body checks daily and she had not received any communication from staff stating that they observed bruising on a resident. Some of staff revealed during their interviews that have observed bruising on the alleged victim but stated that the victim was a fall risk. Some of the staff stated that they assumed the bruises were from the resident falling and not from abuse. Staff 2-8 stated that they never observed staff 7 abusing a resident. Staff 7 denied the allegation and stated that he assisted the resident but did not observe bruising on him. Staff 7 also stated that the resident was a fall risk. LPA interviewed residents 1-5 revealed during their interviews that they like living in the facility and they have not experienced staff being physically abusive with them.

For allegation(Staff handle residents roughly) It was alleged that a staff member handle the residents roughly. The administrator revealed during her interview that she has not received any complaint from her staff or resident about staff 7 handling residents roughly. Staff 2-8 stated that they have not observed staff 7 being rough with residents but some of the staff revealed that they have heard stories from other colleagues about staff 7 being rough with residents. Residents 1-5 revealed during their interviews that the staff are not rough when assisting them.

For allegation (Staff did not properly dispose of soiled diapers.) it is being alleged that staff are not properly disposing resident's diapers and one resident was found in a soiled diaper. The administrator revealed during her interview that staff has not reported and observance of soiled diapers not properly being disposed. The administrator stated that she is unaware of residents being left in soiled diapers. LPA interviewed staff 2-8 about the allegation. One of staff revealed during their interview that the residents will fight and refuse to be changed and the staff have to come back after the residents calms down to proceed with changing. Another staff stated that the residents will take the diapers off themselves and the remaining staff denied the allegation.

For allegation (Staff not speaking to residents respectfully.) It is being alleged that staff 7 is rude to the resident when speaking to them. The administrator stated that she has not personally witness staff 7 or any staff being rude. Staff 7 denied the allegation. Another staff interviewed stated that she has observed staff 7
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jennifer JonesTELEPHONE: (323) 516-3833
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20210105162254
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SILVERADO SENIOR LIVING - BEACH CITIES
FACILITY NUMBER: 197608179
VISIT DATE: 04/01/2021
NARRATIVE
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being rude and to the residents. Staff member revealed that the residents have dementia and will some times curse at staff because they are unaware of what they are saying and staff 7 will curse back at the residents. The remaining of the staff stated that they have not observed staff ? or any other staff being rude to the residents while assisting.

Although the allegation 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 allegation is unsubstantiated.
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jennifer JonesTELEPHONE: (323) 516-3833
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20210105162254
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SILVERADO SENIOR LIVING - BEACH CITIES
FACILITY NUMBER: 197608179
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/16/2021
Section Cited
CCR
87465(e)
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For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. This requirement was not met as
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The administrator will provide proof of training for staff 7 and conduct an additonal inservice training for the nurses regarding administering medication. Administrator will submit by POC due date.
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evidence by: During the investigation, staff 7 admitted to the allegation and stated that he contacted the doctor for a PRN prescription after he administered the medication to the resident.
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Type B
04/16/2021
Section Cited
CCR
87211(a)(1)
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A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... ...This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physican's
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The administrator will review the regulation for reporting requirements and submit documentation to LPA that she read, understands and will adhere to the regulation. Administrator will send by POC due date.
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 name, findings, and treatment, if any; and disposition of the case. This requirment is not met as evidence by: The administrator failed to report a SIR to licensing regarding a resident receiving a medication without a physican's order/
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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: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jennifer JonesTELEPHONE: (323) 516-3833
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6