197608182-6-2-2020-11-AS-MGFS-BQ7V7B-20200602161053

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608182
Report Date: 06/02/2020
Date Signed: 06/02/2020 04:11:23 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME:	SILVERADO SENIOR LIVING - BEVERLY PLACE		FACILITY NUMBER:	197608182
ADMINISTRATOR:	RUSSO, JASON		FACILITY TYPE:	740
ADDRESS:	330 N HAYWORTH AVE		TELEPHONE:	(323) 852-9200
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90048
CAPACITY:	256	CENSUS: 93	DATE:	06/02/2020
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Jason Russo - Administrator		TIME COMPLETED:	04:45 PM

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	Licensing Program Analyst (LPA) Mary Flores conducted a case management visit for a physical abuse allegation. Due to the situation surrounding the Corona virus Disease 2019 (COVID-19), and to implement mitigation measures, today’s case management was conducted telephonically with Jason Russo, the facility administrator. On 1/23/20 LPA Flores conducted a case management visit after facility self reported to the department via an incident report that allegedly a staff observed elder abuse from staff #1 towards clients #1 and #2. LPA Flores met with Administrator Jason Russo discuss the reason of the visit and requested a copy of staff and client roster. LPA interviewed administrator, reviewed staff's #1 and clients' #1 and #2 files, and obtained copies of the following documents at the time of the visit: Incident report and transmission fax report, Police Report copy, clients' #1 and #2 Identification and Emergency Information, Staff's #1 Personnel Record, In - Service Training for the past year, Staff's #1 Copy of First Aid Training, Contact Information of possible witnesses, Staff's #1 Separation Papers will be email to LPA, Staff #1’s training and orientation package. On 1/23/20 LPA Flores interviewed Staff #3 over the phone and send a request to Investigation Bureau of the Department (IB) to take an assignment to interview residents #1 and #2, assignment was accepted by IB. On 1/29/20, Investigator Bureau of the Department (IB) Laura Garcia attempted to contact facility’s Administrator. On 1/31/20, IB – Garcia requested Police Report from Los Angeles Police Department (LAPD), left a voice message for staff #2 and staff #1(S#1, S#2). On 2/6/20, IB made a second attempt to contact S#1 and S#2. On 2/5/20 LPA received change in relationship form for S#1. On 2/13/20, IB collected additional information regarding the incident during a telephone call with Facility’s Administrator. On 2/18/20, IB made a third attempt to contact S#2. On 2/28/20, IB contacted Administrator and confirmed a visit to the facility and attempted again to contact S#2. On 3/2/20, IB made a second request for Police Report to LAPD. On 3/3/20, IB informed LPA Flores that assignment had been upgraded to a full investigation. IB conducted a facility visit, interviewed Residents #1 and #2(R#1, R#2), Staff#4, staff #5 (S#4, S#5), and attempted to contact staff #6 (S#6) over the phone. On 3/16/20, IB received and reviewed incident report #2007-047798-1-6-2020 from LAPD. (Continued on 809C)

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2020

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: SILVERADO SENIOR LIVING - BEVERLY PLACE	FACILITY NUMBER: 197608182
	VISIT DATE: 06/02/2020

NARRATIVE

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On 3/30/20, IB made a field visit to S#1’s residence and left a card. On 4/20/20, IB interview S#2, and S#5 over the phone. On 4/24/20 IB met with S#1 at the department’s office and conducted an interview. On 4/28/20 IB interview staff #7(S#7).

Regarding physical abuse incident report; it was self-reporter to the department that on 1/15/20 S#1 pinned R#1 to the bed with his arm over his shoulder and neck in a head lock position. Additionally, on a different occasion S#1 also flipped another resident unto his bed while performing an “MMA” move. The investigation conducted by Laura Garcia - Investigator Bureau of the department (IB) revealed the following: On 3/3/20, IB investigator attempted to interview R#1 and R#2 due to residents’ cognitive ability investigator was unable to interview. IB interviewed Administrator who stated not to observe the incident and the incident was reported to him immediately by facility’s staff. Administrator contacted LAPD and file a report and terminated allege perpetrator. During IB interviews 1 out 7 staff denied witnessing any inappropriate behaviors by allege perpetrator. Police report received on 3/16/20 stated the officers did not observe any injuries on the victims and there was no evidence of physical abuse. On 4/20/20, IB continued interviews with staff in which, 1 out 7 staff were unwilling to provide any incident details and refused to provide any statements. IB continued interviews with staff in which, 1 out 7 staff stated to be assisting S#1 and S#2 the night of reported incident and denied any type of physical, neglect or inappropriate behaviors by S#1. On 4/24/20, IB conducted an interview with allege perpetrator, who stated that on the day of the incident S#2 asked S#1 and S#6 to assist with R#1 due to history of aggressive and combative behaviors towards staff members. Allege perpetrator indicated to use the holding techniques in which he was trained and were approved by the facility. Perpetrator denied ever using, knowing or practicing mixed martial arts or using “MMA techniques” with residents at the facility. On 4/28/20 IB conducted last interview with staff in which, 1 out 7 staff denied ever witnessing allege perpetrator physically abuse any of the residents, mentioned training and observing allege perpetrator using the appropriate techniques to handle combative residents and described allege perpetrator as a caring individual.

Based on IB's interviews and review of documents, including LAPD Investigative report dated 3/16/20, IB investigator determined the allegation was unsubstantiated. facility reported the incident in a timely manner to all necessary parties and conducted proper assessment for injuries of R#1 and R#2.

No deficiencies were cited. A telephonic exit interview was conducted with Jason Russo, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2020

LIC809 (FAS) - (06/04)

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