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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609117
Report Date: 06/01/2022
Date Signed: 06/01/2022 03:46:12 PM


Document Has Been Signed on 06/01/2022 03:46 PM - It Cannot Be Edited

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 - CALABASASFACILITY NUMBER:
197609117
ADMINISTRATOR:VIDA GWINNFACILITY TYPE:
740
ADDRESS:25100 CALABASAS RDTELEPHONE:
(818) 222-1000
CITY:CALABASASSTATE: CAZIP CODE:
91302
CAPACITY:110CENSUS: 53DATE:
06/01/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Vida Gwinn and Esther Chico-GuiterrezTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management-Legal Non-Compliance inspection at the facility today. The purpose of today’s visit was to ensure the facility was maintaining substantial compliance as outlined in the Stipulation and Waiver; and Order. The order is effective February 25, 2022 – February 24, 2025. Areas discussed:

A. Licensee shall operate the facility in substantial compliance with regulations and statures governing the operation of a residential care facility for the elderly. During today’s visit, the LPA reviewed a random sample of ten staff records. Out of the ten files reviewed, the following was noted:


    a. Four out of ten staff (Staff #2, Staff #3, Staff #6, Staff #7) had a job application that was either incompletely filled out, blank, or missing

    b. Four out of ten staff (Staff #1, Staff #6, Staff #7, Staff #8) had a health screening that was either incompletely filled out or blank

    c. Three out of ten staff (Staff #2, Staff #3, Staff #7) did not have first aid certification on file

    d. Three out of ten staff (Staff #1, Staff #3, Staff #8) require tuberculosis results


B. Career Smart will conduct quarterly audits and have weekly calls with the Administrator. Last quarterly was 3/4/2022 and today, 6/1/2022. Staff confirmed that weekly calls are still taking place. LPA obtained a copy of the quarterly report from 3/4/2022.

C. Licensee will include specific inquiries regarding sexual behaviors and aggressive behaviors during the initial evaluation of new residents Reappraisals will address sexual behaviors and aggressive behaviors when such conduct is evident. Addendum has been added, per licensee. LPA obtained a copy of the addendum. There was one move-in for April and May of 2022 in which facility utilized the new addendum. Copies are kept in a file at the facility.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022
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: 06/01/2022
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D. A member of the licensee’s governing board shall, on a quarterly basis: conduct on site facility visits, review both reports generated by outside consultant and those from CCLD, prepare written reports to the licensee’s governing board, and ensure POCs are completed and submitted timely. On 4/5/2022, Loren B Shook and Michelle Egerer went to the facility. LPA obtained copy of the compliance report.

E. Department shall conduct quarterly inspection during the probationary period. This took place today, 6/1/2022.

F. Licensee shall provide a thirty-minute overlap of direct care staff between each shift. Staff communicated that the time frame is indicated on the staffing assignments to demonstrate the 30-minute overlap. LPA obtained copies.

G. Licensee shall chart any reportable resident injuries on each shift and communicate such injury to direct care staff prior to initiating their shift. Shift change form was created and is being utilized daily. The nurses sign this form during shift change.

H. Licensee shall continue to maintain adequate staffing to meet the specific needs of individual residents in care and population as a whole. Staff are continuing to monitor their staffing numbers. Staffing is reassessed every day, every shift.

I. Licensee shall form a client/resident assessment management that consists of the certified administrator, nursing personnel, and supervising/direct care staff who shall meet at least once a month, in order to reassess the appropriateness of continued placement retention or relocation residents to facilities offering a higher level of care. LPA obtained copy of the meeting notes; staff recently met on 5/31/2022.

J. Licensee shall conduct a monthly support group facilitated by an outside professional approved by the Department, providing an opportunity for associates to share issues/concerns and have a safe environment for communication and sharing without management presence. Dr. Jill Brink came last Thursday 5/26, To maintain confidentiality, the facility is only collecting invoices and the LPA recommended that they include the census. The sessions are two hours - one hour for a group session and one hour for individual check-ins.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: 06/01/2022
NARRATIVE
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K. Licensee shall provide direct care staff a minimum of 6 hours of quarterly training on Title 22 regulations, including but not limited to: Section 87707 and observation of residents, facility’s internal procedures to ensure that observations are included in accurate and up to date charting consistent with facility policy, client behaviors including intimacy and sexual behaviors, interventions with memory impaired residents whom exhibit aggressive behaviors, medication, suspected elder abuse detection and mandated reporting requirements, preparing and providing timely incident reports, proper resident hygiene, health conditions, care of individuals with dementia, the preparation of restricted health condition care plans and the preparation of needs and services plan. The facility holds in-service trainings two hours a month, to ensure that the hours are all completed for direct care staff.

L. Licensee will designate one employee who is fully trained as a caregiver on all shifts as a float staff. Assignment sheets reflecting the person assigned shall be provided to licensing staff during quarterly inspections or whenever requested. If admin/manage met personnel are used as substitute direct care staff, they must engage in direct care during the entire time they are serving in that role. This is indicated on the staff schedule and the daily staffing sheet.

M. Licensee shall assign qualified staff to assess residents who lack the cognitive or physical ability to communicate their needs or injuries on a regular basis as determined by their initial care plan. Documentation of the direct care staff’s observation of any newly identified resident needs or injuries, including pressure injuries, shall be reported to the direct care staff’s immediate supervisor on a daily basis and to the Department, when applicable. On a monthly basis, all residents are assessed for any changes in needs. This is in addition to care plan/service plans that are created for residents.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/01/2022 03:46 PM - It Cannot Be Edited

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: 06/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2022
Section Cited

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87411(a) Personnel Records. The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.
This requirement is not met as evidenced by:
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Based on record review, the licensee did not comply in the section cited above for four out of ten staff (S2, S3, S6, S7), which poses a potential health and safety risk to residents in care.
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Type B
06/10/2022
Section Cited

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87411(f) Personnel Requirements - General. (f) Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.
This requirement is not met as evidenced by:
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Based on record review, the licensee did not comply in the section cited above as for four staff (S1, S6, S7, S8) need a health screening and three staff (S1, S3, S8) need TB results, which poses a potential health and safety risk to residents in care.
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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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5


Document Has Been Signed on 06/01/2022 03:46 PM - It Cannot Be Edited

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: 06/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2022
Section Cited

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87411(f) Personnel Requirements - General. (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by:
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Based on record review, the licensee did not comply in the section cited above in three out of ten staff (S2, S3, S7) need TB results, which poses a potential health and safety risk to residents in care.
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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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022
LIC809 (FAS) - (06/04)
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