197608181-2-17-2021-28-AS-FFIS-BYL6TX-20210225200613

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608181
Report Date: 02/17/2021
Date Signed: 02/17/2021 05:27:46 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 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
01/14/2020 and conducted by Evaluator Bonnie Tao

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200114163259

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: 50	DATE:	02/17/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	GWINN, ALMAVIDA, Administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained unexplained bruising while in care

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Tao initiated a complaint investigation for the allegations 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 Alma Vida Gwinn, the facility administrator.

On 01/15/20, LPA Tao conducted the initial visit, LPA obtained copies of resident #1 to Resident #3's: Physician’s Reports; Admission Agreement; Unusual Incident/Injury Report (except R3); Appraisal Needs & Service Plan, Service Details; Progress Notes; Identification and Emergency Contact Information; and Resident Appraisal. LPA obtained copies of Staff #1 #2 and #3's: Personnel Record, Staff Training, Administrator Certificate, Mandated Reporter Forms and Criminal Record Statements. Besides, LPA obtained copies of resident roster, staff roster, facility floor plan and house rules.

(-continued in LIC 9099 C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021

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 4

Control Number 28-AS-20200114163259

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: 02/17/2021

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 Department investigation consisted of interviews with administrator, Staff # 3, #4, #6, #7, #8, #9, #10, #11, Resident #1, #4, #5, #6 and review of Resident #1's file/medical records and staff file review regarding staff training.

The investigation revealed the following: Resident#1 has dementia, is non-ambulatory, uses a walker to ambulate, is a fall risk and has fallen multiple times in the facility. Per Resident #1 appraisal dated August 29, 2019, Resident #1 may require hands on assistance from staff for mobility/ambulation and staff will monitor and assist Resident #1 for falls as needed for safety. On January 08, 2020, Resident #1 had an unwitnessed fall and was found in the facility hallway. Staff#3 reported resident #1 was observed with red mark on resident’s left side of face/chin and a bridge for front teeth was missing. Staff #3 reported dental treatment was obtained for Resident #1, however, staff #3 reported that there was no increased supervision for resident #1, after the January 08, 2020 unwitnessed fall. On January 9, 2020, Resident #1 had another unwitnessed fall in the facility, staff #5 found Resident #1 outside on the second floor, near the entrance door, while leaning on the walker and visibly upset. On January 09, 2020, after Staff#5 observed Resident #1 with injuries to head, Resident #1 was sent to the emergency room for a head injury. Resident #1 medical reports dated January 09, 2020, indicate that Resident #1 had an unwitnessed fall and sustained various contusions; multiple bruises on resident’s arms, chest and head and suffered an injury to the kidney. The facility failed to address resident #1 need for assistance with ambulating and risk of falls after the January 8, 2020 unwitnessed fall, which resulting in injuries. Resident #1 had another unwitnessed fall on January 9, 2020 which resulted in injuries requiring medical care and there was no staff supervision or care plan in place to ensure resident #1's health and safety. The facility updated resident #1 care plan on January 13, 2020.

Based on LPA observations and interviews which were conducted and record reviews, 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 & Chapter 8, are being cited on the attached LIC 9099D.

Immediate Civil Penalties are being issued on 02/17/21 in the amount of $500.00 due to neglect/lack of supervision resulting in resident #1 injuries which required medical treatment on 01/09/20.

The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f) (-continued in LIC 9099 C)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 28-AS-20200114163259

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/17/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 02/18/2021 Section Cited CCR 87466	1 2 3 4 5 6 7	Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator to submit a statement to Licensing indicating that she has read, understand and will comply with Title 22, Section 87466 by POC due date. Administrator to provide staff training on observation of residents to all staff who provide care and supervision to residents by 02/24/21 and send copy of the in service training log to licensing.
	8 9 10 11 12 13 14	On 1/8/20, resident #1 sustained an injury due to unwitness fall . On 1/9/20, resident #1 sustained another injury due to unwitness fall and sent to hospital. Base on observation, licensee did not update resident#1's Service plan to provide additional care and supervision until after 1/13/20. This poses an immediate health and safety risk to resident.	8 9 10 11 12 13 14
Request Denied Type B 02/19/2021 Section Cited CCR 87405(d)(1)	1 2 3 4 5 6 7	Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator to submit a statement to Licensing indicating that she has read, understand and will comply with Title 22, Section 87405(d)(1) by POC due date
	8 9 10 11 12 13 14	Based on observation, the licensee did not re-evaluate Resident# 1's appraisal after 01/08/20 incident to provide appropricate care and supervison. This poses a potential health and safety risk to resident.	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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20200114163259

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: 02/17/2021

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	A telephonic exit interview was conducted with Alma Vida Gwinn, the facility administrator, appeal rights discussed and a hard copy of LIC 9099s were provided via email for signature.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4