197609117-8-23-2021-29-AS-ASMH-C66SE6-20210823134812

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609117
Report Date: 08/23/2021
Date Signed: 08/23/2021 01:48:33 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: 56	DATE:	08/23/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Taylor Giunto		TIME COMPLETED:	02:00 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	On August 23, 2021 Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management visit to the facility today to follow up on the substantiated allegation of neglect/lack of care and supervision. The LPA met with Executive Director Taylor Giunto and informed them of the reason for the visit. On July 3, 2018, the Department received a complaint which contained the allegations: Facility staff failed to provide proper care and supervision to Resident #1 (R1) which contributed to R1’s death; and, facility staff failed to seek timely medical attention for R1. The above allegations were substantiated, on January 31, 2019, the licensee was cited for violating California Code of Regulations (CCR) Title 22, 87464(f)(1) Basic Services due to failure to provide R1 with proper care and supervision relating to assistance with activities of daily living. Citations were also issued under 87465(g) Incidental Medical and Dental Care for failure to obtain timely medical attention for R1 by failing to call 9-1-1 immediately upon finding R1 in an unresponsive state. The licensee was further cited under section 87411(a) Personnel Requirements – General for not having competent staff to ensure R1 was monitored and ate after receiving insulin, and subsequently failing to contact emergency services for R1 in a timely manner. Lastly, the licensee was issued a citation under section 87405(d)(1)(2) Administrator – Qualifications and Duties for the administrator not providing staff with appropriate training to ensure R1 was afforded appropriate care and supervision, which ultimately contributed to the death of R1. On January 31, 2019, an immediate civil penalty of $500 was also assessed for the violation of CCR Title 22, Section 87464(f)(1) Basic Services. R1’s physician report dated June 27, 2018, revealed that R1 had a primary diagnosis of vascular dementia and Type I diabetes and was confused with times and dates. R1 had a continuous glucose monitor implanted on R1’s arm which transmitted glucose levels to a bedside monitor every five (5) minutes. The display unit was programmed to sound an alarm when R1’s glucose levels dropped below 80 milligrams per deciliter (mg/dl).

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021

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: 08/23/2021

NARRATIVE

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Based on the interviews conducted, a review of facility documentation and R1’s glucose monitor records, on July 1, 2018, Staff #1 (S1), who is a facility Licensed Vocational Nurse (LVN), checked R1’s blood glucose level prior to breakfast. R1 was given six (6) units of Novolog, plus two (2) additional per sliding scale due to R1s blood glucose reading of 274 mg/dl. At approximately 11:46 a.m., R1’s blood glucose level was checked again by S1 and was noted to be at 146 mg/dl. Therefore, S1 administered R1’s afternoon injection of six (6) units of Novolog Insulin and seven (7) units of Tresiba Insulin and instructed R1 to eat. Staff was instructed by R1’s family that R1 must eat a meal after having any of R1’s insulin injections. Per interviews, two (2) caregivers inquired if R1 wanted to eat; however, R1 refused to eat, which the caregivers reported to S1. Per records obtained from R1’s Dexcom monitoring unit, a sharp and rapid drop of R1’s blood glucose level was noted from 11:46 a.m. to 1:45 p.m. and R1’s glucose level dropped below 80 mg/dl at 1:45 p.m. No evidence from facility documentation or the interviews conducted indicated that R1 was monitored by staff from 11:46 a.m. until the sounding of the alarm at 1:45 p.m.

At approximately 1:45 p.m., S1 was conducting afternoon rounds and heard R1’s glucose monitor alarming and noted R1’s blood glucose was dropping to 50 mg/dl. Per interviews, S1 offered R1 chocolate and pudding. However, R1’s glucose did not rise. S1 then contacted Staff #2 (S2) for assistance. S2 and Staff #3 (S3) responded to the call and noted R1 appeared lethargic, sluggish and was not able to answer and soon became unresponsive. S2 then placed a call to R1’s primary care physician (PCP) regarding R1’s condition and awaited directions. Facility staff contacted 9-1-1 at 2:33 p.m. after receiving instructions from R1’s PCP to send R1 to the hospital. Los Angeles County Fire Department (LACFD) arrived at the facility at 2:38 p.m. At 2:39 p.m., R1’s pulse, respiration, and systole (heartbeat) were all reported to be zero (0) and R1 was pronounced deceased at 2:40 p.m. Per R1’s death certificate, the cause of death was noted as cardiopulmonary arrest, probable respiratory failure, probable congestive heart failure. Other significant conditions contributing to death, but not resulting in the underlying cause, was noted to be diabetes mellitus type I uncontrolled, stroke, and vascular dementia. An autopsy was completed on July 9, 2018, which noted the final diagnosis as juvenile diabetes mellitus, severe cardiovascular arteriosclerosis, early pulmonary fibrosis with pleural adhesions and severe right and left sided cardiac osseous metaplasia (heart calcification).
As per the Mayo Clinic, “Hypoglycemia is a condition in which your blood sugar (glucose) level is lower than normal. Hypoglycemia needs immediate treatment when blood sugar levels are low. For many people, a fasting blood sugar of 70 milligrams per deciliter (mg/dL), or 3.9 millimoles per liter (mmol/L), or below should serve as an alert for hypoglycemia.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021

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
	VISIT DATE: 08/23/2021

NARRATIVE

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The investigation consisted of interviews with facility personnel, residents, medical professionals, law enforcement and other relevant parties. Copies of supportive facility documentation, medical records, the autopsy report and additional pertinent documentation was also obtained and reviewed.

Based on interviews, the licensee failed to monitor R1 for change of condition after administering the insulin injection. In addition, the licensee failed to seek timely medical care for R1 after R1 was found in an unresponsive state. Therefore, the allegations that facility staff failed to provide proper care and supervision to R1; and, facility staff failed to seek timely medical attention for R1 were substantiated.

On January 31, 2019, the licensee was informed that a civil penalty might be assessed based on Health and Safety Code §1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Per Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.”

Today, August 23, 2021, the Department is issuing a civil penalty per Health and Safety Code §1569.49 in the amount of $10,000 for a violation that the Department constitutes as serious bodily injury. However, since an immediate civil penalty of $500 was previously issued on January 31, 2019, the amount of the civil penalty issued is reduced to $9,500. A copy of the LIC 421D was given to Taylor Giunto and originals were signed.

Exit interview conducted. A copy of the report issued. Appeal Rights provided. Taylor Giunto’s signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021

LIC809 (FAS) - (06/04)

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