197609117-11-29-2021-31-AS-JAPL-C9D39J-20211203170309

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609117
Report Date: 11/29/2021
Date Signed: 11/29/2021 12:24:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/03/2018 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 31-AS-20180703114242

FACILITY NAME:	SILVERADO SENIOR LIVING - CALABASAS		FACILITY NUMBER:	197609117
ADMINISTRATOR:	SAMMY HASSAN		FACILITY TYPE:	740
ADDRESS:	25100 CALABASAS RD		TELEPHONE:	(818) 222-1000
CITY:	CALABASAS	STATE: CA	ZIP CODE:	91302
CAPACITY:	110	CENSUS: 58	DATE:	11/29/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Taylor Giunto		TIME COMPLETED:	12:20 PM

ALLEGATION(S):

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Facility staff failed to provide proper care and supervision to Resident #1 (R1) which resulted in R1’s death.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced subsequent complaint visit to the above facility. The LPA met with Executive Director Taylor Giunto and explained the reason for the visit.

On 01/31/2019, the Department issued findings of Substantiated for the above allegation. The licensee was cited for violating California Code of Regulations (CCR) Title 22, 87464(f)(1) Basic Services, in which “Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2.” An immediate civil penalty of $500 was also issued. An appeal was issued by the licensee, and the deficiency was dismissed. After further review, the Department has determined that the allegation, “Facility staff failed to provide proper care and supervision to Resident #1 (R1) which resulted in R1’s death” will be changed from Substantiated to Unsubstantiated. The $500 penalty will be dismissed. Although the Department is no longer substantiating the above allegation, the Department found that facility staff failed to provide proper care and supervision to Resident #1 (R1), which resulted in serious bodily injury and will be addressed in a Case Management visit. Exit interview conducted. A copy of the report was issued.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021

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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