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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608180
Report Date: 08/23/2025
Date Signed: 08/23/2025 11:15:36 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/19/2025 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250219161002
FACILITY NAME:SILVERADO SENIOR LIVING - THE HUNTINGTONFACILITY NUMBER:
197608180
ADMINISTRATOR:ROCHELLE CARPIOFACILITY TYPE:
740
ADDRESS:1118 N STONEMAN AVETELEPHONE:
(626) 308-9777
CITY:ALHAMBRASTATE: CAZIP CODE:
91801
CAPACITY:62CENSUS: 57DATE:
08/23/2025
UNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Ruth Thuku, Charge Nurse Rochelle Carpio, Administrator TIME COMPLETED:
11:14 AM
ALLEGATION(S):
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Staff did not prevent resident from inappropriately touching himself in front of other residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alberto Lopez conducted a subsequent visit to deliver findings. LPA arrived unannounced and met with Ruth Thuku, Charge Nurse and assisted with the visit. Administrator Rochelle Carpio was on the phone during the visit and reading of the report. The purpose of the visit was explained.

The investigation consisted of: On 02/19/2025, LPA toured the facility, obtain copies of the staff and resident roster, and conducted a health and safety check. On 02/25/2025, LPAs interviewed five (5) staff and six (6) residents, reviewed, and obtained Resident #1-#4(R1 -R4) pertinent documents, Alhambra Police Department incident number and name of officer, copy of email dated 02/18/2025, Nurses progress notes from 2/19/2024 to 02/20/2025, R2 face sheet, Physician’s Report for Residential Care Facilities for the Elderly (RCFE), R1 Medication List, R1 progress notes from 01/24/2024 to present. R1 service plan dated 02/25/2025. Incident report dated 02/21/2025 regarding R1 and R2. R1 Behavior Mapping dated 02/18/2025. R1 Power of Attorney dated 04/19/2024. R1 California Probate Code Section 4701 dated 08/13/2018. R1 client interest intake dated 12/23/2023. R1 mini mental dated 07/22/2024. R1 Diet Request Form. (Continued on 9099C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2025
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 28-AS-20250219161002
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SILVERADO SENIOR LIVING - THE HUNTINGTON
FACILITY NUMBER: 197608180
VISIT DATE: 08/23/2025
NARRATIVE
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(continued from 9099A)

The investigation revealed: Regarding Allegation: Staff did not prevent a resident from inappropriately touching self in front of other residents in care. It is alleged that the resident was inappropriately exposing self in front of the other residents. LPA interviewed six (6) staff and four (4) of six (6) staff corroborated the allegation by stating to have observed R1 masturbating multiple times, Staff were aware of R1’s tendency to masturbate in R1’s room, and that R1 was placed on medication to assist with behavior. Due to cognitive skills, R1 and R2 were not able to be interviewed. Per documents reviewed, R1 was admitted to the facility on 12/23/2023. Progress notes show on the following dates R1 showed inappropriate sexual behaviors; 01/28/2024, 03/08/2024, 03/09/2024, 04/27/2024, 05/01/2024, 05/06/2024, 05/09/2024, 06/26/2024, 08/10/2024. On 07/14/2024, R1 made an inappropriate sexual comment towards R1’s roommate and their visitors. On 09/24/2024, Facility contacted R1’s physician and was provided with medication to assist with inappropriate sexual behaviors. On 2/18/2025 Facility staff observed R1 on top of their roommate, with R1’s pants down. At 8:33am, staff #4(S4) emailed the facility’s nurses and management team regarding R1’s inappropriate behavior towards roommate (R2).

Per records reviewed the facility Administrator was aware of R1’s behavior between January of 2024 to August of 2024. It wasn’t until 9/24/2025 that the facility staff contacted R1’s physician to seek assistance with behaviors. The facility staff did not protect the personal rights of the residents in care by providing assistance sooner and/or providing a private space for R1. Therefore, there is sufficient evidence to support this allegation.

Based on interviews conducted and record review, 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 LIC9099D.

An exit interview was conducted. A copy of this report, Plan of Correction, and Appeal Rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Citations on this Visit Report are Under Appeal!

Control Number 28-AS-20250219161002
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SILVERADO SENIOR LIVING - THE HUNTINGTON
FACILITY NUMBER: 197608180
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
08/24/2025
Section Cited
CCR
87468.2
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(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: (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 evidence by:
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Licensee will create a plan to deal with inappropriate behaviors showing steps, documentation, and considerations of privacy, will train facility staff on the plan and provide a copy to the department by POC date 08/24/2025
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Based on documents reviewed and interviews, licensee did not ensure R1’s inappropriate sexual behavior disturbed other residents in care which poses an immediate risk to the personal rights, health, or safety of the persons in care.
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Under Appeal
Type A
08/24/2025
Section Cited
CCR
87405(h)(3)
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87405(h)(3)
Administrator - Qualifications and Duties
(h) The administrator shall have the responsibility to: (3) Develop an administrative plan and procedures to ensure clear definition of lines of responsibility, equitable workloads, and adequate supervision.

This requirement is not met as evidenced by:
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Licensee will ensure Administrator is aware and/or takes the necessary continue education to address inappropriate behaviors in a timely manner to be able to plan and train staff to address the behaviors and will submit a copy of education obtained by POC due date 8/24/2025
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Based on interviews and documents reviewed, licensee did not ensure the administrator seek appropriate intervention for R1 in the course of (eight) 8 months which poses an immediate risk to the personal rights, safety, and health of the persons in care.
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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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5