197609117-9-21-2021-29-AS-TCAA-C73PL5-20210921112412

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609117
Report Date: 09/21/2021
Date Signed: 09/21/2021 11:25:21 AM

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:	09/21/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Kim Davis, Director of Healthcare Services		TIME COMPLETED:	11:45 AM

NARRATIVE

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On September 21, 2021, Licensing Program Analyst (LPA), Teresa Camara conducted an unannounced Case Management visit to follow up on a substantiated allegation of lack of supervision. The LPA met with Director of Healthcare Services Kim Davis and informed them of the reason for the visit.

On August 23, 2021, the Department issued findings regarding the complaint received on July 16, 2019, alleging that due to the facility’s failure to provide appropriate care and supervision, Resident #1 (R1) sustained injury(ies). More specifically, the complaint alleged that on July 13, 2019 Resident #2 (R2), a 71-year-old male without warning pushed R1, an 88-year old male, in the back and he was hospitalized for serious lacerations to his forehead, mouth, and nose.

The allegation was substantiated and the licensee was cited for violating California Code of Regulations (CCR) Title 22, §87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities., in which “Residents shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.” On August 26, 2021, an immediate civil penalty of $500 was assessed; in addition, the Department also assessed a $1000 civil penalty due to the citation being a repeat violation of the same subsection.

continued on 809-C (page 2)

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SILVERADO SENIOR LIVING - CALABASAS	FACILITY NUMBER: 197609117
	VISIT DATE: 09/21/2021

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The investigation revealed that on July 13, 2019, at approximately 11:50 a.m., per Staff #1 (S1) she observed R1 standing in the hallway when R1 was pushed on the back by R2, causing R1 to fall face first on the ground. S1 observed lots of bleeding from R1’s nose, mouth, and forehead, as well as bruising to R1’s forehead and stomach. Staff #2 (S2) mentioned that they were standing near R1 when the incident occurred and stated that R2 had pushed other residents in the past. Staff #3 (S3), the facility Licensed Vocational Nurse (LVN), was in her office, which is near the location of where the incident occurred, rendered first aid, but was unable to stop the bleeding. S3 contacted 9-1-1 and R1 was admitted to a local hospital emergency department at approximately 12:51 p.m. Hospital medical records reflect R1 was admitted from the hospital emergency department to the hospital intensive care unit (ICU) on the same day at 5:01 p.m.

Per hospital records R1 was admitted with the following diagnoses: stable burst fracture of the first cervical vertebra; acute respiratory failure-unspecified with hypoxia or hypercapnia’ anterior displaced type II dens fracture; contusion of abdominal wall, contusion of right front wall of thorax; fracture of nasal bones; and laceration without foreign body of nose. A ‘burst’ fracture, according to Cedars Sinai, is a descriptive term for an injury where the vertebra is crushed in all directions and is more severe as the bones spread out in all directions and can damage the spinal cord. According to the US National Library of Medicine, an anterior displaced type II dens fracture, occurs most typically when the cervical spine hyperflexes, pushing the vertebrate forward to the point of fracture. According to the US National Library of Medicine, hypoxia is a state in which oxygen is not available in sufficient amounts at the tissue level to maintain homeostasis, which can be caused by airway obstruction.

continued on 809-C (page 3)

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SILVERADO SENIOR LIVING - CALABASAS	FACILITY NUMBER: 197609117
	VISIT DATE: 09/21/2021

NARRATIVE

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R1 was in the ICU and on a ventilator until July 22, 2019 when the family made the decision to extubate him and he passed away. The death certificate lists the immediate cause of death as respiratory failure. According to the National Heart, Lung, and Blood Institute, respiratory failure is a serious condition that develops when lungs can’t get enough oxygen into the blood, which can be a condition that is often caused by a disease or injury to the lung or spinal cord.

As a part of the investigation, R2’s resident file was reviewed. R2 was admitted to the facility on November 8, 2018 and his August 17, 2018 physician’s report indicated a primary diagnosis of Alzheimer’s Disease and Anxiety. His April 23, 2019 Comprehensive Assessment and Service Plan reflected R2’s behavior of wandering/pacing, a history of Alzheimer’s Dementia, anxiety, paranoia, combative, uncooperative with activities of daily living (ADL) assistance. Other facility records and staff interviews revealed since placement R2 had incidents of aggressive behaviors, verbally and physically, towards facility staff and residents, as well as being hit by other residents. Some of the incidents include: December 8, 2018 female resident bit him on arm; April 13, 2019 R2 bit a caregiver who was providing ADL care; July 1, 2019, R2 hit a caregiver on the arm, and later hit a resident on the hands; July 9, 2019, R2 hit a facility staff member; and July 12, 2019 after being grabbed on the arm, R2 responded by hitting the resident on the shoulder. Reportedly none of these incidents required medical intervention. Staff interviews revealed additional aggressive incidents, including picking up a male staff and slamming him against a wall three times. There is no written evidence that the licensee made efforts to increase his supervision, until after the assault of July 13, 2019 against R1, when the 1 on 1 caregiver was assigned.

continued on 809-C (page 4)

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SILVERADO SENIOR LIVING - CALABASAS	FACILITY NUMBER: 197609117
	VISIT DATE: 09/21/2021

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Based on the interviews conducted and records reviewed, there was sufficient evidence to substantiate the allegation of lack of care and supervision, which led to R1 sustaining significant injuries leading to his death. The facility failed to implement adequate safety measures to address and manage R2’s repeated aggressive behavior, which posed an immediate health and safety risk to the other residents in care and staff.

On August 23, 2021, 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 a violation which resulted in the death of R1.

Today, September 21, 2021, the Department is issuing a civil penalty per Health and Safety Code §1569.49 in the amount of $15,000 for a violation that the Department determined resulted in the death of R1. However, since an immediate civil penalty of $500 was previously issued on August 26, 2021, the amount of the civil penalty issued is reduced to $14,500. A copy of the LIC 421D was given to the Director of Healthcare Services Kim Davis and originals were signed.

Exit interview conducted. A copy of the report issued. Appeal Rights provided. Director of Healthcare Services Kim Davis' 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: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

LIC809 (FAS) - (06/04)

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