197608182-4-21-2021-11-AS-MVAO-C36RGP-20210519130104

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608182
Report Date: 04/20/2021
Date Signed: 04/21/2021 04:36:56 PM

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 DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/27/2020 and conducted by Evaluator Erik Brown

COMPLAINT CONTROL NUMBER: 11-AS-20201027164256

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:	0	CENSUS: 103	DATE:	04/20/2021
		UNANNOUNCED	TIME BEGAN:	02:08 PM
MET WITH:	Myla Belson, Administrator		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Resident sustained pressure injury while in care.
Staff not supervising resident resulting in fall(s).
Staff not seeking medical attention for resident.
Staff not keeping facility free from odor.
Facility is dirty.

INVESTIGATION FINDINGS:

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On this date, Licensing Program Analyst (LPA) Erik Brown conducted an unannounced complaint tele-visit to deliver findings. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Myla Belson, the facility Administrator.

During the initial visit on 10/28/2020, LPA Williams interviewed Staff #1-5, regarding the complaint. LPA also requested documentation regarding the complaint allegation.

During the visit on 3/11/2021, LPA Brown interviewed Staff #6 - #8 (S6-S8) and residents #2-6 (R2-6), regarding the complaint. LPA also requested further documentation regarding the complaint allegation.

During the visit on 3/12/2021, LPA Brown interviewed Staff #9 - #11 (S9-S11) and residents #7-11 (R7-11), regarding the complaint. LPA also requested further documentation regarding the complaint allegation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Erik Brown	TELEPHONE: (747) 230-2283
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021

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 11-AS-20201027164256

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SILVERADO SENIOR LIVING - BEVERLY PLACE	FACILITY NUMBER: 197608182
	VISIT DATE: 04/20/2021

NARRATIVE

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The investigation revealed the following for allegation:

(Resident sustained pressure injury while in care.)
(Staff not supervising resident resulting in fall(s).)
(Staff not seeking medical attention for resident.)
(Staff not keeping facility free from odor.)
(Facility is dirty.)

Based on review of medical documentation from Silverado Hospice Los Angeles, it was documented that R1 had a DTPI to the mid-back, left heel, right heel, right lateral foot, left lateral foot on 9/18/2020. R1 was not ambulatory and needed help with ADLs but was not bedridden. There is nothing in hospice notes that states that R1 needed to be repositioned every so often to prevent pressure injuries. It was first noted by the facility on 8/20/2020 that R1 had a red area on the right mid-back. The facility nurses addressed the wounds and had R1 admitted to Silverado Hospice Los Angeles on 9/18/2020.

According to interviews, the facility has enough staff coverage across different shifts and staff supervise residents at all times. The facility staff verbalized that they know and understand the protocol for when a resident falls in the facility. Residents have a call button for assistance. Some residents also have body alarms if they are residents who are confused and disoriented and attempting to get up. Staff indicated an awareness of when to seek medical attention for residents, one of the indicators being any change of condition. Staff also stated that they are trained to call 9-1-1 for any resident that needs immediate medical attention.

Residents and staff generally stated that the facility does not have an odor unless a resident is actively being changed. Residents generally stated that the facility is kept very well. Residents also stated that they have not seen the facility being dirty.

Based on the information obtained, per interviews, and record review, there was insufficient evidence that Silverado Senior Living - Beverly Place acted negligently. Silverado Hospice Los Angeles believes
that the facility complied with and maintained the care plan for R1.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Erik Brown	TELEPHONE: (747) 230-2283
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20201027164256

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SILVERADO SENIOR LIVING - BEVERLY PLACE	FACILITY NUMBER: 197608182
	VISIT DATE: 04/20/2021

NARRATIVE

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Based on LPA Brown’s observations, the records that were reviewed (R1's hospice wound care plan, needs and services plan, physician's report, pre-placement appraisal), and the interviews that were conducted by LPA Brown and LPA Williams, although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

A telephonic exit interview was conducted with Administrator Myla Belson and an electronic copy was provided via email for signature.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Erik Brown	TELEPHONE: (747) 230-2283
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021

LIC9099 (FAS) - (06/04)

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