197609117-10-21-2020-29-AS-DPEA-BUM28M-20201021171035

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609117
Report Date: 10/21/2020
Date Signed: 10/21/2020 05:11:33 PM

Document Has Been Signed on 10/21/2020 05:11 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 - 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:	10/21/2020
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Taylor Giunto		TIME COMPLETED:	04:45 PM

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Licensing Program Analysts (LPAs) Desaree Perera and Ashley Smith initiated an unannounced Case Management – Incident visit to the above facility. The purpose of this visit is to conclude an investigation initiated during a Case Management – Incident visit conducted on 07/31/2019 by LPA Perera. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted virtually via FACETIME with administrator Taylor Giunto at 3:13pm. Entrance interview conducted.

On 07/25/2019, the Department received a Special Incident Report (SIR) which reflected that on 07/23/2019, Resident #1 (R1) and Resident #2 (R2) were both found by Staff #1 (S1) in R1’s bedroom undressed from the waist down. Both residents were redirected and neither residents had any noted injuries. During the initial visit conducted on 07/31/2019, the LPA conducted a brief tour of the physical plant and reviewed the video surveillance footage of the facility between approximately 9:10am and 9:50am. The LPA also conducted interviews with facility staff between 10:00am and 10:50am. Documentation pertinent to the incident was also obtained and reviewed between 11:20am and 12:02pm. Furthermore, on 08/07/2019 between 1:39pm -2:15pm; and, on 12/11/2019 at 3:08pm, interviews were conducted with family and/or responsible party of residents. Additional staff interviews were also conducted on 09/04/2019 between 10:40am and 11:33am. Documents were also obtained and reviewed on 08/07/2019.

Information obtained also revealed that R1’s initial Individualized Service Plan (ISP) dated 07/11/2019 noted a diagnosis of Alzheimer’s disease and behavioral disturbance. R1’s cognition included short and long-term memory loss and dementia which “requires assist with daily decision making.” R1’s mental/psychological/emotional health noted that R1 participates in amorous behavior with residents. In response, facility intervention would be to “redirect as needed but otherwise respect resident right to intimacy.” The Service Plan Conference Sheet dated 07/25/2019, addresses R1’s intimate encounters with residents.

Continued on LIC809-C...

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Desaree Perera	TELEPHONE: (747) 230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020

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: 10/21/2020

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Furthermore, during the conference, Facility Director of Health Services discussed with the family of R1 how facility staff redirects R1 in these situations, the assignment of a one to one (1:1) caregiver for observation and modification of medication. Additionally, R1’s initial evaluation with R1’s Primary Care Physician (PCP) dated 07/18/2019 to establish R1’s care needs, reflects R1 has a diagnosis of “…Alzheimer’s Dementia, behavioral problems, anxiety, increased sexual behavior…” Furthermore, the evaluation notes R1 has “memory problems.” R1’s physician’s report dated 05/28/2019, completed by R1’s prior PCP of 25 years notes that R1 is confused/disoriented, has inappropriate, aggressive, wandering and sundowning behaviors.

Per Resident #2’s (R2’s) physician’s report dated 11/02/2018, R2 has a primary diagnosis of Dementia likely mixed vascular and Alzheimer’s Disease. R2 is also noted to be confused/disoriented, and has aggressive, and sundowning behaviors. Moreover, per R2’s Initial Individualized Service Plan (ISP)/ Comprehensive Assessment and Service Plan dated 01/03/2018, it notates under “Cognition/Thinking ability” that R2 “Has Dementia – Requires assist with daily decision making” and further notes under “Communication” R2 has “Dementia – Difficulty Communicating.”

A review of Resident #3’s (R3’s) facility records revealed that per the physician’s report dated 06/21/2018, R3 has a primary diagnosis of Alzheimer’s Disease and is confused/disoriented. R3’s Initial Individualized Service Plan (ISP)/Comprehensive Assessment & Service Plan also notates under “Cognition/Thinking ability” that R3 “Has Dementia – Requires assist with daily decision making” this remained unchanged on the Bi-Annual assessment conducted on 08/02/2018. The Bi-Annual assessment further notes that R3 has “Dementia – difficulty communicating.”

Information obtained and reviewed during the course of the investigation revealed on 07/23/2019 at 6:43am, R1 exits R1’s room and at the same time R3 enters R1’s room fully clothed. R1 walks down the hallway and then goes back to R1’s room at approximately 6:44am. Video surveillance did not show any facility staff checking on the residents at this time. At approx. 6:45am, R1 comes back out of the room and walks towards the front lobby while adjusting R1’s pants. At approximately 6:50am, R1 and R2 are observed walking towards R1’s bedroom. R1 is observed with R1’s hands around R2, leading R2 to the room. At approximately 6:53am, S1 is observed walking with another resident but does not do any room checks/rounds. At 6:54am, S1 is observed walking into R1s bedroom. It appears that the door was closed/locked and S1 opens and goes into the room for approximately 30 seconds and then exits.

Continued on LIC809-C...

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Desaree Perera	TELEPHONE: (747) 230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020

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: 10/21/2020

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No residents are observed exiting the bedroom at this time. S1 appears to have walked to the Front Wellness area. At approximately 6:58am, a different staff checks only the room across from R1’s room, but no other room. At approximately 7:06am, two unidentified females (possible other agency staff) are observed walking down the hallway by R1’s room. The two females slow down by R1’s room and look towards the room and then continue to walk. At approximately 9:08am, S1 walks into R1’s room and walks back out; and then, at 9:10am, S1 walks back into R1’s room. The video surveillance footage shows facility staff #2 (S2) and staff #3 (S3) walking to R1’s room. In addition, at 9:11am, staff #4 (S4) is observed walking into the room as well. At 9:13am, S2 walks out R1’s bedroom to a different room then walks back to R1’s room with an item of clothing and what appears to be an adult diaper. At 9:15am, S1 walks out to the room next to R1s room. At 9:16am, S2 walks R3 out of R1’s room in to R3’s room wearing only adult diapers and transfers R3 over to S1. S2 then walks back into R1’s bedroom. At 9:17am, S2 and S3 appear to be standing outside the door of R1’s room and S4 arrives at the scene and is observed having a conversation with the two staff. At 9:20am, two caregivers are observed finally removing R2 out of R1’s room while S2 and S3 hold R1 back.

Interviews conducted revealed that that facility caregivers were aware of R1’s behavior and were informed to monitor R1 closely, at least every 30 minutes. However, staff failed to redirect residents, even after being found in the room the first time at 6:54am. When staff did a check/rounds at 9:08am, R1 and R2 were in R1’s bed, undressed from the waist down, and R3 was on the other bed in the room, wearing only adult diapers. R1, R2 and R3 were left unsupervised in R1s room for approximately 2 hours and 58 minutes.

Interviews conducted and documents reviewed further reflected that R2’s POA did not have the legal authority to give consent to R2’s relationships; and, R2 did not have the mental capacity to consent to being in bed with R1. Based on all information gathered, there is sufficient evidence to determine that due to lack of care and supervision and R2’s serious disability, R2 was a victim of sexual battery by R1. Based on the evidence obtained, the LPA was unable to determine if there were any inappropriate actions involving R3.

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 809-D).

Exit interview conducted/ Appeal rights provided/ A copy of this report was emailed for signature.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Desaree Perera	TELEPHONE: (747) 230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/21/2020 05:11 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: 10/21/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 10/22/2020 Section Cited	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on interviews, record and surveillance review, the licensee did not comply with the above section by failing to provide the appropriate care and supervision to residents which resulted in R2 being sexually battered by R1, which is an immediate health and safety risk to resident in care.	8 9 10 11 12 13 14
Request Denied Type A 10/22/2020 Section Cited	1 2 3 4 5 6 7	Basic Services. (f) 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(c). This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on interviews, record and surveillance review, the licensee did not comply with the above section by failing to provide care and supervision to R1, R2, and R3 which resulted in R1 and R2 being undressed from the waist down in R1’s bed.	8 9 10 11 12 13 14

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: Desaree Perera	TELEPHONE: (747) 230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020

LIC809 (FAS) - (06/04)

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