197609117-8-23-2021-31-AS-JAPL-C67RUL-20210824132006

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609117
Report Date: 08/23/2021
Date Signed: 08/23/2021 01:55:13 PM

Substantiated

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
07/16/2019 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 31-AS-20190716075339

FACILITY NAME:	SILVERADO SENIOR LIVING - CALABASAS		FACILITY NUMBER:	197609117
ADMINISTRATOR:	TAYLOR GIUNTO		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
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Taylor Giunto		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Due to facility lack of care and supervision, Resident #1 (R1) sustained injury(ies).

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Smith conducted a subsequent complaint visit to the above facility. The purpose of today’s visit is to conclude an investigation initiated by LPA Desaree Perera on 07/17/2019. The LPA met with Taylor Giunto and explained the reason for the visit. Entrance interview conducted.

It was alleged that due to facility lack of care and supervision, Resident #1 (R1) was pushed by Resident #2 (R2) on 07/13/2019. R1 fell face first right on to the floor and was bleeding profusely from R1’s forehead, nose and mouth. It was further reported that R2 has had multiple incidents where R2 was aggressive towards other residents and staff.

On 07/17/2019, LPA Perera conducted an initial 10-day visit, at which time a file review was conducted, and copies of pertinent documentation were obtained. LPA Perera also conducted a brief tour of the physical plant at 9:20am. Investigator Dennis Douglas from Community Care Licensing Division’s Investigation Branch (CCLD’s IB) conducted the investigation.

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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20190716075339

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: 08/23/2021

NARRATIVE

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On 08/14/2019, 11/02/2019 and 11/06/2019, Investigator Douglas conducted interviews with facility staff and residents. On 08/14/2019, 08/20/2019, 8/22/2019, 09/19/2019 and 10/25/2019, Investigator Douglas conducted interviews with Detectives from Los Angeles County Sheriffs Homicide Division. On 11/06/2019, interviews were conducted with Home Care Assistance personnel, which was the private agency who provided one-on-one (1:1) supervision for R2. Investigator Douglas obtained and reviewed Hospital Medical Records on 07/25/2019. Moreover, facility video surveillance footage and other pertinent documentation was also reviewed by Investigator Douglas.

Record reviews and interviews conducted regarding the incident revealed that, on 07/13/2019, R2 pushed R1 in the back causing R1 to fall face first on the ground and R1 was observed bleeding from R1’s nose, mouth and forehead. The attack was unprovoked and without warning. Several staff members were present in the area of the facility where the incident occurred and witnessed the attack as it occurred. As a result of the injuries, R1 was transported to the Emergency Room (E.R). Per medical record review, R1 was admitted to the E.R. on 07/13/2019 and was diagnosed with the following: 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, laceration without foreign body of nose. R1 was terminally extubated per family request and ultimately passed away at the hospital on 07/22/2019.

Documents reviewed and interviews conducted revealed that R2 was admitted to the facility on 11/08/2018. Per R2’s physician report dated 08/17/2018, R2 has a primary diagnosis of Alzheimer’s dementia and anxiety. The report further notates, R2 is confused/disoriented, has inappropriate and wandering behavior. The report did not indicate R2 had aggressive behaviors. However, records reflected that R2’s aggressive behaviors dated as far back as 11/16/2018. R2’s Comprehensive Assessment and Service Plan dated 04/23/2019, indicates R2 has some behavioral concerns such as “yelling” and “attempting to strike CG (caregivers).” The assessment further noted that R2 “bit” a caregiver on 04/13/2019. Investigation further revealed that prior to the incident that occurred on 07/13/2019, R2 had a history of numerous aggressive behaviors both verbally and physically towards staff and other residents. On 07/01/2019, R2 hit a caregiver on the arm and once redirected, went into a resident room and hit a resident on the hands. On 07/09/2019, R2 hit a facility staff member. On 07/12/2019, another resident grabbed R2’s arm, and R2 hit the resident on the shoulder in response. As a result of the incident that occurred on 07/13/2019, R2 was placed on one-on-one care from 07/13/2019 (post-incident) through 07/26/2019.

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

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20190716075339

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: 08/23/2021

NARRATIVE

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Based on all information gathered and reviewed during the course of the investigation, the department has sufficient evidence to determine that due to lack of care and supervision, R1 was pushed by R2, which resulted in R1 sustaining serious injuries. The facility staff were aware of R2’s behaviors; however, they failed to implement adequate safety measures to address and manage R2’s repeated aggressive behavior. It was foreseeable and regularly documented that R2’s aggression posed a risk to other residents in care. Therefore, the above allegation “Due to facility lack of care and supervision, Resident #1 (R1) sustained injury(ies)” is SUBSTANTIATED at this time.

A $500 immediate civil penalty is assessed today. 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).

Pursuant to Title 22, California Code of Regulations, the following deficiency will be cited (refer to LIC 9099-D)

Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report has been issued.

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

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20190716075339

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: 08/23/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 08/24/2021 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities. 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.	1 2 3 4 5 6 7	The Administrator has agreed to do the following: 1. Submit a Plan of Action/Protocol, detailing how staff are trained to proactively manage aggressive behaviors with residents diagnosed with dementia.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as R1 was pushed by R2 and sustained multiple injuries due to lack of care and supervision, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	2. Schedule an in-service training for caregivers and LVNs that specifically speaks to managing aggressive behaviors. Submit proof of completion to CCLD. Facility was cited for this on 3/30/2021, civil penalty of $1000 assessed for repeat violation.
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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 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021

LIC9099 (FAS) - (06/04)

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