197608180-2-2-2023-28-AS-TVAO-CPJQUM-20230302112858

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608180
Report Date: 02/02/2023
Date Signed: 02/02/2023 03:40:02 PM

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
03/23/2021 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210323120245

FACILITY NAME:	SILVERADO SENIOR LIVING - THE HUNTINGTON		FACILITY NUMBER:	197608180
ADMINISTRATOR:	SAFOORA AHMED		FACILITY TYPE:	740
ADDRESS:	1118 N STONEMAN AVE		TELEPHONE:	(626) 308-9777
CITY:	ALHAMBRA	STATE: CA	ZIP CODE:	91801
CAPACITY:	62	CENSUS: 43	DATE:	02/02/2023
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Arienne Ghammangne, Wellness Director		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Neglect/lack of supervision resulting in resident sustaining a fracture while in care.
Staff did not ensure resident was wearing hip protector.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to deliver findings for the allegations listed above. LPA met with Wellness Director, Arienne Ghammangne, and explained the purpose of the visit.

The investigation consisted of the following:
On 3/24/2021, LPA Chan conducted the initial visit virtually due to the situation surrounding the Coronavirus Disease 2019 (COVID-19). LPA toured the facility virtually and did not observe any immediate health and safety concerns at the time. LPA requested copies of the staff and resident rosters including phone numbers, and documents for 4 residents. On 10/25/22, LPA interviewed the current Administrator, 5 Staff, and 5 Residents. The Department of Social Services Investigation Bureau Investigator (IB) Tiffany Brunelli assisted with the allegation - neglect/lack of supervision resulting in resident sustaining a fracture while in care.

(Continue on the LIC9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

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-20210323120245

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: 02/02/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The investigation revealed the following:
Allegation - Neglect/lack of supervision resulting in resident sustaining a fracture while in care. IB Investigator T. Brunelli conducted interviews and reviewed records pertaining to Resident #1 (R-1) who fell and fractured a hip on 1/2/2021. According to the Impactactive waiver form that was signed by R-1's family member on 10/31/2019, it authorized the facility to order 3 pairs of hip protection garments for R-1 to use. On 1/2/21, R-1 was not wearing a hip protector, had a fall in the facility courtyard and sustained a hip fracture. Per the interviews with staff, some acknowledged that R-1 had worn a hip protector prior to the fall. During that time period, the facility had many staff off due to testing positive for the Coronavirus. The facility had brought in care staff from outside agency to assist residents and one was assigned to R-1. The caregiver daily assignment sheet dated 1/2/2021 did not indicate that R-1 should be wearing a hip protection garment, as shown with the label "hp" next to some other resident's names. It was verified that R-1 was not wearing a hip protection garment on the day of the fall. Based on the information gathered, there is sufficient evidence to show that there was negligence from the facility for failure to ensure R-1 wears a hip protector, which could had prevented resident from sustaining a fracture.

Allegation - Staff did not ensure resident was wearing hip protector. According to current Administrator Carpio, any resident who signs the impactactive waiver form, the facility orders 3 pairs of hip protectors and the staff ensure the residents wear them. The staff are given their daily assignment, and the list will indicate “hp” next to the names of residents who signed up for the hip protection garment. Upon admission, R-1’s family signed up to purchase hip protectors for R-1 to wear, which could help reduce the risk of having a hip fracture from a fall. Based on the caregiver daily assignment sheet dated 1/2/2021, residents who are supposed to wear a hip protector had a “hp” labeled next to the name and was confirmed there is no “hp” indicated next to R-1’s name. Therefore, the registry staff assigned to care for R-1 possibly could not have known that R-1 needed to wear the hip protector. On that same day, R-1 was not wearing a hip protector and sustained a hip fracture from a fall.

Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today. Refer to LIC 421IM*** The issuance of an additional Civil Penalty is being considered based on health & Safety Code 1569.49(f); If the Department determines serious bodily injury occurred.

An exit interview was conducted. The Plan of Corrections were reviewed and developed with A. Ghammangne. A copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

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
03/23/2021 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210323120245

FACILITY NAME:	SILVERADO SENIOR LIVING - THE HUNTINGTON		FACILITY NUMBER:	197608180
ADMINISTRATOR:	SAFOORA AHMED		FACILITY TYPE:	740
ADDRESS:	1118 N STONEMAN AVE		TELEPHONE:	(626) 308-9777
CITY:	ALHAMBRA	STATE: CA	ZIP CODE:	91801
CAPACITY:	62	CENSUS: 43	DATE:	02/02/2023
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Arienne Ghammangne, Wellness Director		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

A resident sustained pressure injuries while in care.
Staff did not respond to resident's alarm.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20210323120245

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: 02/02/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The investigation revealed the following:
Allegation - Resident sustained pressure injuries while in care. It was alleged that Resident #1 (R-1) had open pressure wounds on the ankles and a small pressure wound on the back. Based on interviews conducted with the staff, they recalled R-1's leg being elevated and was wearing a boot. They also stated that the home health nurse was treating the wound. Staff indicated that when they observe redness on any resident's body, they would report it right away to the nurse. Based on the record review, R-1 did have a pressure wound on the ankle in which a home health nurse was treating. It was also noted that R-1 had a firm mass in the lower right back which was discovered on 2/26/21. The medical doctor was notified on the same day and was monitoring the mass. Although R-1 sustained these pressure injuries, there were no sufficient evidence showing a lack of supervision or neglect from the staff.

Allegation - Staff did not respond to resident's alarm. It is alleged that Resident #1 (R-1) had several falls due to staff not hearing the tab alarm. LPA Chan interviewed the Administrator and 5 Staff. Administrator stated that staff are constantly walking around to monitor residents, about every 2 hours or more often if needed. Staff denied not responding to resident's alarm. They stated when they hear the tab alarms go off, they will immediately check on residents. The tab alarm, which are clipped on their clothing, are loud enough where staff are able to hear from the hallways. According to staff, R-1 had used a tab alarm but also knows how to remove it to avoid the alarm sound. When staff noticed it was removed, they would reattach it on resident and explain to resident the importance of having it on. Staff also denied R-1 having several falls due to staff not hearing the tab alarm. Staff mentioned that when they arrived in resident's room, R-1 was seen on the ground. However, there were no injuries noted nor was there any witnesses that resident fell to the ground.

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

An exit interview was conducted with A. Ghammangne. A copy of this report along with the appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20210323120245

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: 02/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 02/03/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator shall develop a plan to ensure that all residents who signs up for the Impactactive waiver are provided with the hip protection garment. This plan shall be submitted to LPA by the POC due date 2/2/23.
	8 9 10 11 12 13 14	Based on interviews and records review, the facility failed to ensure that R1 was wearing a hip protector garment and resulted in a hip fracture which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	In addition, an in-service training shall be provided to all care staff to ensure hip protectors are worn. This training log shall be submitted to LPA by POC date 2/9/23. A civil penalty of $500 is being issued.
Request Denied Type A 02/03/2023 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities...(4) To care, supervision, and services that meet their individual needs and are delivered by staff... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator shall provide a plan to ensure all residents who requested for a hip protector garment are wearing one by POC due date 2/2/23.
	8 9 10 11 12 13 14	Based on interviews, staff did not ensure that R1, who was supposed to be provided a hip protector, was wearing one which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5