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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608179
Report Date: 04/28/2022
Date Signed: 04/30/2022 09:11:53 PM

Substantiated


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
MONTERY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/07/2019 and conducted by Evaluator Lourdes Montoya
COMPLAINT CONTROL NUMBER: 11-AS-20191107144525
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:0CENSUS: DATE:
04/28/2022
UNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Lack of supervision resulting in injury
Staff did not seek medical treatment for resident in a timely manner
Staff did not properly care for residents wound
Staff did not properly care for resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lourdes Montoya made an unannounced visit to the facility and was greeted by Director of Health Services. Ponce called Administrator Lourdes Menchaca and Mecnaca joined the visit by phone. The purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.

An initial 10-Day virtual visit was conducted on 11/08/19 at 10:20 a.m. with Administrator (Daizel Gasperian) and Director of Health Services (Maureen Longbine). During this visit, interviews were not conducted of residents and staff. However, LPA Lourdes Montoya reviewed eight (8) resident records and obtained copies of three (3) of the eight (8) residents’ records which included: Physician's Report, Admissions Agreement, Comprehensive Assessment Service Plan, Medication Administration Record, Progress Notes, Facility Physician Consult Notes, Pre-placement Report, Appraisal/Needs and Services Plan, Identification and Emergency Information, Incident Reports, Home Healthcare Notes, Physician Consults, Residents Roster, Staff Roster, Shift Schedule, Training Records, and Administrator Certificate.

Report Continued in LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
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 5
Control Number 11-AS-20191107144525
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
MONTERY PARK, CA 91754
FACILITY NAME: SILVERADO SENIOR LIVING - BEACH CITIES
FACILITY NUMBER: 197608179
VISIT DATE: 04/28/2022
NARRATIVE
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A separate investigation was conducted by the Department of Social Services Investigator (Brian Slatic) which included a review of Progress Notes, Incident Reports, Resident #1’s Files, Omni Wound Physicians Records, and Chronological Record of Photos & Events; interviews were conducted of the Reporting Party, Facility Administrator, Asst. Director of Health Services, Former Acting Director of Health Services, Facility LVNs (S3-S6), and Omni Wound Physician Assistant. The facility was approved for a change of ownership from subtenant to LLC but the managing partners remain the same.

Regarding Allegation #1 Lack of Supervision Resulting in Injury: Investigation’s Branch (IB) investigation revealed that on 10/13/19 at approximately 7:00 pm, in an open and spacious hallway outside the activity room, Resident #1 (R1) was kicked by Resident #2 (R2) after R1 reportedly kicked R2 first. There were three (3) caregivers (S8-S10) and a Charge Nurse (S4) on shift supervising 21 residents at that time on the 4th floor. One caregiver was inside the activity room and another caregiver was in the hallway. Facility staff failed to adequately supervise two (2) dementia residents and intervene before injury (skin tear: 8x8x0.12cm) could occur. R1 has resided at the facility since 7/17/2017 and primary diagnosis with Dementia and Hypertension. During the interview with the Administrator (S1), it was confirmed that the above incident occurred on 10/13/19. During the interview with Staff #2 (S2) it was revealed S2 was not familiar with what went on from the initial skin tear on 10/13/19 until the documentation of the wound on 10/30/19 on R1’s progress notes. It was revealed in interviews that Staff #3 (S3) and Staff #4 (S4) did not know about the kicking incident that caused R1’s shin tear. Staff #5 (S5) stated that R1’s family member approached her on 11/6/19 and showed her a photo of R1’s wound. Based upon the evidence gathered and interviews conducted, and records reviewed, the preponderance of evidence standard has been met: R1 sustained a wound on left shin, when R1was kicked by R2; therefore, the above allegation of lack of supervision resulting in injury is found to be SUBSTANTIATED.

Regarding Allegation #2 Staff Did Not Seek Medical Treatment for Resident in a Timely Manner: IB investigation revealed that the incident was documented on 10/13/19 as a skin tear and was treated and dressed at the time of the incident. IB’s interview revealed, S4, a floater LVN on the 4th floor, was alerted by another staff (unidentified) regarding R1’s skin tear sustained in the kicking incident on 10/13/2019. S4 immediately went to the hallway and treated R1’s skin tear. S4 made a phone call to R1’s family and reported the incident. S4 stated she worked on the 4th floor again on the evening of 10/14/2019 where S4 met R1’s family and explained the kicking incident and treatment S4 provided on

Report Continued in LIC 9099-C

SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20191107144525
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
MONTERY PARK, CA 91754

FACILITY NAME: SILVERADO SENIOR LIVING - BEACH CITIES
FACILITY NUMBER: 197608179
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/13/2022
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement is not met as evidenced by:
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Administrator agreed to conduct a staff in service training and will provide LPA a sign in sheet regarding a review of the cited section of Title 22 on Personal Rights. POC wiill be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
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Based on observatiions, interviews and records review, staff did not properly care for residents and resident's wound. There was a lapse of care between 10/14/2019-11/7/2019. A progress note written by S3 dated 10/30/19 documented S3 reported R1 has a skin tear on R1’s left lower shin. The next progress note dated 11/7/2019 was dealing with the left lower shin wound; and it stated that R1’s physician issued a new order for antibiotics. The first dose of antibiotics was given; and, the wound care was due to start on 11/08/19. This poses an immediate risk to client's health, safety and personal rights.
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**Immediate Civil Penalties is being assessed in the amount of $500.00.**
Type B
05/13/2022
Section Cited
CCR
87405(d)(1)
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87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
(1) Knowledge of the requirements for providing care and supervision appropriate to the residents.
This requirement is not met as evidenced by:
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Administrator shall submit a self certification stating the cited section of Title 22 on Personal Rigjts was reviewed. POC will be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
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Based on observatiions, interviews and records review, staff did not properly care for residents and resident's wound. The Administrator admitted during an interview that the facility nurse did not follow up on the skin tear as quickly as it should have been due to the lapse of care. The Administrator characterized it as a misstep. The Administrator confirmed the lack of follow up during the period from 10/13/19 until the wound documentation dated 10/30/19. This poses an immediate risk to client's health, safety and personal rights.
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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: Lourdes MontoyaTELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20191107144525
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
MONTERY PARK, CA 91754
FACILITY NAME: SILVERADO SENIOR LIVING - BEACH CITIES
FACILITY NUMBER: 197608179
VISIT DATE: 04/28/2022
NARRATIVE
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10/13/2019. S4 noticed a different dressing on R1’s skin tear and thought someone must have changed it. However, per review of the facility’s progress note of R1, there was no documentation of wound treatment to R1 on 10/13/2019 and 10/14/2019. No further treatment was documented on the chart until 10/17/19 that states “R1 noted with seeping to the skin tear on the left shin, provided wound care due to bandage being soiled, will continue to monitor”, No further documentation of wound was noted until 10/30/19, when Staff #3 (S3) documented a skin tear on R1’s left lower shin of “unknown origin”.

S3, who is an LVN, provided wound treatment and notified R1’s physician. R1’s physician returned orders on 10/31/19 for wound treatment and a wound consult. There was no further charting or other documentation to show that any wound treatment, dressing change or wound consultation was provided to R1 between 10/30/19 and the evening of 11/06/19 when R1’s family member discovered the poor condition of the dressing on the left shin’s wound. On 11/17/19 progress notes indicated that Ceftin mg was prescribed to R1 by the physician and was seen by a wound consultant from Omni Wound Physicians. The first dose of antibiotics was given. There was a lapse of care between 10/14/19 – 11/7/19. Progress notes revealed that facility staff and Omni Wound Physicians continued the wound care for R1 on 11/7/19. The Administrator (S1) confirmed in an interview that there was a lack of follow-up during the period of time from the kick on 10/13/19 until the wound documentation on 10/30/19. S4 revealed that S4 went to the scene on the day of the incident on 10/13/19 and treated R1’s skin tear but he did not provide a follow-up treatment because S4 did not work on the 4th floor where R1’s room was located. S3 admitted that S3’s first knowledge of R1’s shin wound was on 10/30/19, and then S3 wrote the incident report. S2 stated that S2 was notified by a facility nurse on 11/6/19 about R1’s shin wound. S2 stated on 11/7/19, the physician’s orders were being implemented for R1 and S2 believed the wound care was being done daily. S5 stated R1’s family member approached S5 on 11/6/19 and showed S5 a photo of R1’s wound and S5 agreed that R1’s wound looked infected. Based upon the evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has been met: Staff failed to seek timely medical attention for R1’s left shin wound; therefore the above allegation of staff did not seek medical treatment for resident in a timely manner is found to be SUBSTANTIATED.

Regarding Allegations #3 & 4 Staff Did Not Properly Care for Resident and Resident’s Wound: IB’s investigation revealed an internal incident report documented on 10/13/19 treatment was rendered, wound cleansed, skin replaced back to its original wound area (measured 8x8x0.12 cm), medication was applied, covered with Telfa, 4x4 gauze, wrapped with Kerlix, and secured with tape. A progress note dated 10/17/19,

Report Continued in LIC 9099-C

SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20191107144525
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
MONTERY PARK, CA 91754
FACILITY NAME: SILVERADO SENIOR LIVING - BEACH CITIES
FACILITY NUMBER: 197608179
VISIT DATE: 04/28/2022
NARRATIVE
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stated that the skin tear on the left shin was seeping through the bandage. Wound care was provided by facility LVN due to the bandage being soiled. The next progress note dated 10/30/19 read that a skin tear was noted as “unknown origin”. It stated, no bleeding, no sign of infection or discomfort; first aid was initiated, physician and family was notified. A progress note written by S3 dated 10/30/19 documented S3 reported R1 has a skin tear on R1’s left lower shin; but the progress note read like it was a new injury, not the existing one that occurred on 10/13/19. The Administrator admitted during an interview that the facility nurse did not follow up on the skin tear as quickly as it should have been due to the lapse of care. The Administrator characterized it as a misstep. The Administrator confirmed the lack of follow up during the period from 10/13/19 until the wound documentation dated 10/30/19. The next progress note dated 11/07/19 was dealing with the left lower shin wound; and it stated that R1’s physician issued a new order for antibiotics. In addition, home health agency Omni Wound Physicians was ordered to begin services. The first dose of antibiotics was given; and, the wound care was due to start on 11/08/19. Based upon the evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has been met: Facility staff did not regularly observe R1’s left shin injury which later required wound care; therefore, the above allegation of staff did not properly care for resident and residents wound is found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiencies were observed, and citations issued (ref. LIC 9099D) and civil penalty assessed.

At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, “a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.”

An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights were provided to Director of Health Services Jessica Ponce.

SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5