197609117-10-19-2020-29-AS-JAPL-BUSMH6-20201027093702

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609117
Report Date: 10/19/2020
Date Signed: 10/19/2020 04:41:24 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
05/18/2020 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20200518142052

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:	10/19/2020
		UNANNOUNCED	TIME BEGAN:	04:15 PM
MET WITH:	Taylor Giunto		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident sustained multiple pressure injuries while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced complaint visit to deliver the findings for the above allegation. 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 5/18/2020, the Department received a complaint stating that on 5/12/2020, resident #1 (R1) was admitted to the hospital with a stage 3 pressure injury on the hip, a stage 1 pressure injury on the coccyx and a lesion on the private region. Community Care Licensing Division’s Investigations Branch (IB) Investigator Joseph Balarie was assigned to the case. On 5/19/2020, the LPA interviewed the Executive Director at 9:18am. Investigator Balarie reviewed medical records on 5/26/2020, interviewed a medical professional on 6/16/2020 at 10:45am; interviewed a family member on 6/10/2020 at 12:05pm; interviewed staff on 6/24/2020 at 12:40pm and 6/25/2020 at 11:10am, 11:20am, and 2:20pm; and, interviewed a physician on 7/2/2020 at 3:40pm.

Substantiated

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: 10/19/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2020

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 29-AS-20200518142052

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/19/2020

NARRATIVE

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Interviews and documentation review revealed that R1 was hospitalized on 5/12/2020 at approximately 9:16pm with the chief complaint of decreased appetite and possible COVID-19. The preliminary diagnosis, according to documentation, was viral sepsis and COVID-19 with multiple comorbidities. Upon admission, the following was observed: left hip stage 3 pressure injury (photographed on 5/13/2020 at 4:49am), deep tissue injury on right hip, (photographed on 5/13/2020 at 4:51am), coccyx stage 1 pressure injury (photographed on 5/13/2020 at 4:55am), left elbow skin tear (photographed on 5/13/2020 at 4:51am), herpetic lesion in private area (photographed on 5/13/2020 at 4:52am), and left shin abrasion (photographed on 5/13/2020 at 4:54am). R1 was discharged from the hospital on 5/15/2020 on hospice.

At the time of hospitalization, R1 was not receiving wound care services from a home health or hospice agency. Documentation review revealed that R1 was previously on hospice but was discharged October 2019. However, Facility Progress Notes show that on 5/12/2020, a note mentioned that due to a decline in health, R1 was to be admitted to hospice. Facility Progress Notes regarding R1 revealed that on 5/10/2020, it was documented that R1 was ‘noted with non-blanchable red area on R hip measuring approx 2inx1.25in … dark purple area of discoloration approx. nickel-sized in middle of reddened area. On the L hip there is an open area of skin measuring approx. 2inx1.5in; skin surrounding open area is reddened yet intact. Resident will be repositioned q2h to prevent further skin breakdown. POA to be updated in AM. Staff will continue to monitor’. Although it was noted that R1 was to be repositioned every two hours, there were no additional notes present detailing the worsening of the pressure injuries, nor if any additional care was administered.

Interviews revealed that at the time of R1’s hospitalization, R1’s family was unaware of the pressure injuries or abrasions present on R1’s body. Interviews described R1 as being ‘almost 100 percent bedbound’ with a steady decrease in mental and physical health. R1’s most recent Comprehensive Assessment and Service Plan, dated 5/2019, noted that R1 was evaluated under fair health and needed maximum assistance on all physical activities. Additional interviews revealed varied information as to whether staff observed any pressure injuries, redness, or skin irritation on R1 prior to R1’s hospitalization on 5/12/2020. Interviews revealed that redness was allegedly observed on R1’s hips 5/11/2020; however, there was no documentation or admittance to note whether this was relayed to a nurse on duty. Facility policy stated that caregivers must notify the charge nurse on duty if any new or persisting injuries are observed on a resident. At the mention of R1 obtaining a pressure injury on the left hip, interviews revealed that it was ‘unsurprising’ and R1 often slept on their left side.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2020

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20200518142052

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/19/2020

NARRATIVE

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Based on the information provided, there is sufficient evidence to support the claim R1 developed multiple pressure injuries while in care. Upon hospital admission, R1 was observed with multiple pressure injuries, including a stage 3 pressure injury on the left hip. In addition, facility staff were not aware of the pressure injuries or rash in R1’s private areas. R1 was not under the care of hospice or home health prior to hospitalization on 5/12/2020. This allegation is Substantiated at this time.

The following deficiency is observed (See LIC 9099-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. An immediate $500 civil penalty assessed. The licensee was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Exit interview conducted. A copy of the report was provided via email for signature, along with the 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: 10/19/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2020

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20200518142052

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/19/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/21/2020 Section Cited CCR 87615(a)(1)	1 2 3 4 5 6 7	Prohibited Health Conditions. Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) stage 3 and 4 pressure injuries. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator has agreed to do the following: 1. Executive Director will review Regulation 87615 regarding Prohibited Health Conditions. A Statement of Understanding will be submitted by 10/21/2020.
	8 9 10 11 12 13 14	Based on the investigation, record review and interview, licensee did not comply with the above section due to R1 sustaining a stage 3 pressure injury, yet R1 was not under the care of hospice or home health services for wound care, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	2. Charge nurses wlill review Regulation 87615(a)(1); Executive Director will inform CCLD when this is completed no later than 10/22/2020. Immediate civil penalty of $500 was also assessed.
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	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: 10/19/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2020

LIC9099 (FAS) - (06/04)

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