197608181-4-28-2021-28-AS-MVAO-C2WPJL-20210511112142

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608181
Report Date: 04/27/2021
Date Signed: 04/28/2021 09:00:02 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 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
07/14/2020 and conducted by Evaluator David Sicairos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200714114454

FACILITY NAME:	SILVERADO SENIOR LIVING - SIERRA VISTA		FACILITY NUMBER:	197608181
ADMINISTRATOR:	GWINN, ALMAVIDA		FACILITY TYPE:	740
ADDRESS:	125 W SIERRA MADRE AVE		TELEPHONE:	(626) 812-9777
CITY:	AZUSA	STATE: CA	ZIP CODE:	91702
CAPACITY:	87	CENSUS: 0	DATE:	04/27/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:			TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident is being abused by staff.
Facility did not safeguard resident's property.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Sicairos completed a complaint investigation for the allegations listed above.

The investigation consisted of the following: during initial televisit conducted on 07/15/20, LPA conducted a virtual tour of facility and common areas with the assistance of Selene Rangel who is the Senior Director of Health Care Services. On 08/06/20, 08/13/20 and 09/18/20, LPA conducted phone interviews with the Administrator, Staff #1(S1) - Staff #5 (S5), and Resident #1 (R1) - Resident #9 (R9). LPA also received various documents from R1's file which included 2 police reports from the Azusa Police Department.

The investigation revealed the following: in regards to the allegation "resident is being abused by staff", it is alleged that on 07/11/20 R1 was handled in a rough manner by a staff member which caused bruising on R1's wrist and upper arm areas. (CONTINUED ON 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021

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 28-AS-20200714114454

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SILVERADO SENIOR LIVING - SIERRA VISTA	FACILITY NUMBER: 197608181
	VISIT DATE: 04/27/2021

NARRATIVE

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Azusa Police Department was also contacted and conducted a Welfare Check on 07/12/20 and 07/15/20. Based on Welfare Check's conducted by Officer Gomez and Officer Hildebrandt which included interviews with all parties involved, the bruises observed on R1 were consistent to the lifting technique used to lift a resident from the bed to a wheel chair. The officers did not suspect elder abuse. LPA interviews conducted with S1 - S5 all denied any sort of abuse towards any residents at the facility including R1. Interview with R1 revealed that R1 felt that staff members sometimes handle her in a rough manner when they are assisting her with transfers from bed to wheelchair. LPA interviews conducted with R2 - R9 all denied experiencing any type of abuse from any staff members at the facility. Therefore, there was insufficient evidence to corroborate with the allegation.

In regards to the allegation "facility did not safeguard resident's property", it is alleged that R1 is often seen wearing the same clothes and facility has lost some of her clothing. Interviews conducted with S1 - S5 all indicated that they were not aware of R1 missing any clothing items. Staff members interviewed indicated that R1 is changed on a daily basis and/or as needed, and dirty laundry is picked up daily and washed on-site. Staff members indicated that items sometimes temporarily go missing due to the Dementia residents they serve, however the items are usually recovered and returned to their owners. A Clothing Assessment Form was completed for R1 upon move-in, and a Personal Property Disclaimer form was signed by R1's Responsible Party on 06/03/20 which states that "Silverado is not able to reimburse for lost clothing or other expensive articles for personal use". Interviews conducted R2 - R9 indicated that they have not had any personal belongings gone missing at the facility. Therefore, there was insufficient evidence to corroborate with the allegation.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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.

Facility has been closed as of 03/08/21. Reason for closure was Change of Ownership. Hard copy of report will be mailed to the Licensee's last known mailing address.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021

LIC9099 (FAS) - (06/04)

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