197609117-10-20-2020-29-AS-ASMH-BUKSRU-20201020140652

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609117
Report Date: 10/20/2020
Date Signed: 10/20/2020 02:07:08 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SILVERADO SENIOR LIVING - CALABASAS		FACILITY NUMBER:	197609117
ADMINISTRATOR:	GIUNTO, TAYLOR		FACILITY TYPE:	740
ADDRESS:	25100 CALABASAS RD		TELEPHONE:	(818) 222-1000
CITY:	CALABASAS	STATE: CA	ZIP CODE:	91302
CAPACITY:	110	CENSUS: 53	DATE:	10/20/2020
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Taylor Giunto		TIME COMPLETED:	11:00 AM

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) Ashley Smith conducted an unannounced Case Management – Incident visit to the above facility. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s investigation was conducted virtually via FaceTime with Executive Director Taylor Giunto.

On 5/7/2020, the Department received a special incident report (SIR), stating that on 5/3/2020, staff #1 (S1) failed to properly assist resident #1 (R1) with the self-administration of medication. R1 was hospitalized due to increased lethargy and abnormal vital signs. On 5/12/2020, the Department was notified that R1 passed away. Community Care Licensing Division’s (CCLD) Investigations Branch (IB) Investigator Joseph Balarie was assigned to the case. On 5/14/2020, the LPA interviewed the Executive Director at 3:03pm. Investigator Balarie reviewed medical records on 6/4/2020, interviewed S1 on 7/3/2020 at 11am, interviewed staff on 6/24/2020 at 12:40pm and 6/25/2020 at 11am, and interviewed a physician on 7/2/2020 at 4:10pm.

Interviews and documentation review revealed that on 5/3/2020, S1 delivered the incorrect medications to R1 at approximately 10am. S1 realized later that day that they had administered incorrect medication to R1 and checked R1’s vitals. Whereas vitals seemed normal, R1 appeared lethargic. S1 sought medical advice and was advised to call 9-1-1. Medical records revealed that R1 was hospitalized on 5/3/2020 at approximately 3:59pm with the chief complaint of possible medication overdose. However, medical records determined that although R1 was given the incorrect medication, upon evaluation, there were no adverse side effects at the time of admission. R1 stayed at the hospital under observation until the medication ‘wore off’. R1 was tested in the hospital for COVID-19 and results were positive. On 5/5/2020, S1 showed signs of a low-grade fever, which continued to spike on 5/6/2020, 5/7/2020, and 5/8/2020. On 5/10/2020, it was discovered that R1 had pneumonia, COVID-related. On 5/11/2020, R1 developed respiratory distress and was transferred to ICU. Comfort measures were initiated on 5/11/2020 and R1 passed away on 5/12/2020.

CONT- 809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020

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

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SILVERADO SENIOR LIVING - CALABASAS	FACILITY NUMBER: 197609117
	VISIT DATE: 10/20/2020

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

Hospital medical records revealed that the ingestion of incorrect medications did not have an adverse reaction to R1’s well-being. Interviews revealed that due to R1’s weight and height, positive COVID-19 test result, and prolonged health conditions, those were the main contributing factors to R1’s passing. A review of R1’s death report identified the immediate cause of death as cardiorespiratory failure, probable myocardial infraction, and coronary artery disease. The death certificate identified COVID-19 as a significant condition contributing to R1’s death.

Based on the information obtained, there is insufficient evidence to support the claim that R1 passed away due to ingesting incorrect medication. However, there is sufficient evidence to support the claim that S1 failed to properly assist R1 with the self-administration of medication, which resulted in R1 becoming increasingly lethargic and subsequently hospitalized for observation.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Civil penalties assessed. Exit interview conducted. A copy of the report was provided via email for signature, along with appeal rights.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SILVERADO SENIOR LIVING - CALABASAS	FACILITY NUMBER: 197609117
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/20/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/22/2020 Section Cited	1 2 3 4 5 6 7	Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed by each facility. The plan shall ... provide for assistance in obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on observation, record review and interview, licensee did not comply with the above section as S1 failed to properly assist R1 with the self-administration of medication, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Facility was cited for this on 3/5/2020. Civil penalty of $250 assessed for repeat violation.
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020

LIC809 (FAS) - (06/04)

Page: 3 of 3