<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609117
Report Date: 10/21/2020
Date Signed: 10/21/2020 05:08:12 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
08/30/2019 and conducted by Evaluator Desaree Perera
COMPLAINT CONTROL NUMBER: 31-AS-20190830120316
FACILITY NAME:SILVERADO SENIOR LIVING - CALABASASFACILITY NUMBER:
197609117
ADMINISTRATOR:GIUNTO, TAYLORFACILITY TYPE:
740
ADDRESS:25100 CALABASAS RDTELEPHONE:
(818) 222-1000
CITY:CALABASASSTATE: CAZIP CODE:
91302
CAPACITY:110CENSUS: 53DATE:
10/21/2020
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Taylor GiuntoTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Lack of care and supervision resulted in resident on resident sexual abuse
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Desaree Perera and Ashley Smith initiated a subsequent complaint visit to the above facility. 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. The purpose of the virtual visit is to conclude an investigation initiated by LPA Perera on 08/30/2019. Entrance interview conducted.
It was alleged that a lack of care and supervision resulted in resident on resident sexual abuse between Resident #1 (R1) and Resident #2 (R2). It was reported that facility staff failed to properly supervise R1 and R2 which resulted in R1 and R2 having sexual intercourse.
On 08/30/19, LPA Perera conducted an initial 10-day visit, at which time copies of pertinent documentation were obtained and reviewed. Investigator Jose Santana from Community Care Licensing Division’s Investigation’s Branch (CCLD IB) conducted the investigation.

Continued on LIC 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Desaree PereraTELEPHONE: (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.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 31-AS-20190830120316
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: 10/21/2020
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 On 09/06/2019, 09/11/2019, 09/17/2019, 09/18/2019, 09/26/2019, 10/11/2019, 12/02/2019 and 12/11/2019, IB Investigator Santana conducted interviews with facility staff. On 09/06/2019, 09/17/2019, 09/18/2019, and 10/19/2019, Investigator Santana conducted interviews with facility residents and family/responsible parties. Additionally, on 09/09/2019, 09/11/2019, 10/11/2019, and 01/27/2020, Investigator Santana conducted interviews with other relevant parties, including but not limited to, the Lost Hills Sheriff’s Department staff, Long Term Care Ombudsman (LTCO) and medical professionals. Moreover, video surveillance footage and records relevant to the allegations were obtained and reviewed by Investigator Santana on 09/25/2019 and 07/28/2020.
Information gathered 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. Furthermore, during the conference, the Facility Director of Health Services discussed with the family of R1 how facility staff redirects R1 in these situations, and 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, was to establish that R1’s care needs reflect that R1 has a diagnosis of “…Alzheimer’s Dementia, behavioral problems, anxiety, increased sexual behavior…” Furthermore, the evaluation notes that R1 has “memory problems.” R1’s physician’s report dated 05/28/2019, which was completed by R1’s prior PCP of 25 years notes, R1 is confused/disoriented, has inappropriate, aggressive, wandering and sundowning behaviors.
Records reviewed for R2 reflected R2’s physician’s report dated 03/21/2018 and notes R2’s primary diagnosis as Dementia with behavioral disturbances, R2 is confused/disoriented, displays inappropriate, aggressive, and sundowning behavior. Furthermore, the report notes R2 to be non-ambulatory based on both their physical and mental condition. R2’s pre-admission/initial Comprehensive Assessment dated 03/20/2018 listed diagnoses of dementia with behavioral disturbance, psychosis, and osteoarthritis of the knees, hands, and feet with a prior elbow fracture. Additionally, R2’s Bi-Annual Comprehensive Assessment & Service Plan dated 05/15/2019, indicates R2 “Has Dementia – Requires assist with daily decision making” under “Cognition/Thinking ability” and the assessment further states R2 has “Dementia – Difficult Communicating” under “Communication/To make sure to recognize when R2 needs help.”
Continued on LIC9099-C....
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Desaree PereraTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 31-AS-20190830120316
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: 10/21/2020
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
In an assessment conducted on the day of the incident, 08/19/2019, R2’s PCP notes R2 has poor insight, is not oriented to time, place or person. R2’s PCP further notes R2 needed to be monitored due to an increased sex drive related to a disturbance associated with dementia.
Information gathered during the course of the investigation revealed that on 08/18/2019 between 0814 and 0923 hours, R1 and R2 were inside a facility bedroom having sexual intercourse, as discovered by Staff #1 (S1). Prior to this incident, R1 had a history of sexualized behavior, of which the facility was aware. Between R1’s admission to the facility on 07/11/2019, to this incident on 08/18/2019, R1 was found partially naked inside bedrooms with other residents on seven (7) separate occasions. R1 was assigned a one on one (1:1) caregiver between 07/26/2019 and 08/11/2019 to help manage R1’s aggressive behavior; however, this 1:1 was discontinued, even though incidents kept occurring between R1 and other residents.
All evidence gathered reflected that the facility’s intent was to curtail R1’s sexualized behavior by redirecting R1 away from intimate interactions with residents through increased supervision, and by curbing R1s libido through medications; but, the facility ultimately failed to manage the behavior, resulting in intercourse occurring between R1 and R2. R1 did not have Power of Attorney (POA) authorization to engage in intercourse and both R1 and R2 lacked the mental capacity to consent. Interviews conducted revealed that facility staff are instructed to redirect R1 whenever found in a bedroom with another residents.
Facility video surveillance video shows that R1 and R2 were inside the bedroom for one (1) hour and eight (8) minutes before a caregiver did a room check. Many facility staff members walked down the hallway, but none stopped to open the door despite instructions to monitor R1 every 30 minutes. In addition, interviews also reflected that the facility was short staffed on the day of the incident. Information gathered revealed S1 and S2, who were responsible for R1 and R2 were the only two caregivers during the shift and were required to fill-in for caregivers who did not report to work on the day of the incident. S1 and S2’s resident assignment exceeded the facility’s caregiver-to-resident ratio of 1:7 by more than double; therefore, R1’s whereabouts were not monitored for over an hour. Based on all information gathered during the course of the investigation, the above allegation “lack of care and supervision resulted in resident on resident sexual abuse” is deemed 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/ Appeal rights provided/ A copy of this report was emailed for signature.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Desaree PereraTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 31-AS-20190830120316
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: 10/21/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/22/2020
Section Cited
CCR
87468.1
1
2
3
4
5
6
7
 87468.1 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:
1
2
3
4
5
6
7
Administrator will submit a plan on what action will be taken to ensure all residents are accorded dignity and appropriate care by POC due date
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 resident on resident (R1 and R2) sexual abuse, which is an immediate health, safety and personal rights risk to residents in care.
8
9
10
11
12
13
14
Request Denied
Type A
10/22/2020
Section Cited
CCR
87411
1
2
3
4
5
6
7
Personnel Requirements – General. (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator will submit a comprehensive plan on what action will be taken to ensure facility maintains sufficient staffing at all times.
8
9
10
11
12
13
14
Based on interviews, record and surveillance review, licensee did not comply with the above section by failing to have sufficient personnel to ensure all residents are provided care and supervision, which is an immediate health and safety risk to residents in care.
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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Desaree PereraTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
08/30/2019 and conducted by Evaluator Desaree Perera
COMPLAINT CONTROL NUMBER: 31-AS-20190830120316

FACILITY NAME:SILVERADO SENIOR LIVING - CALABASASFACILITY NUMBER:
197609117
ADMINISTRATOR:GIUNTO, TAYLORFACILITY TYPE:
740
ADDRESS:25100 CALABASAS RDTELEPHONE:
(818) 222-1000
CITY:CALABASASSTATE: CAZIP CODE:
91302
CAPACITY:110CENSUS: 53DATE:
10/21/2020
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Taylor GiuntoTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident #2 (R2) sustained a broken hand due to abuse
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Desaree Perera and Ashley Morgan initiated a subsequent complaint visit to the above facility. 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. The purpose of the virtual visit is to conclude an investigation initiated by LPA Perera on 08/30/2019. Entrance interview conducted.

It was alleged that Resident #2 (R2) sustained a broken hand during sexual intercourse with Resident #1 (R1), which resulted from facility staff failing to provide adequate supervision. On 08/30/019, LPA Perera conducted an initial 10-day visit, at which time copies of pertinent documentation were obtained and reviewed. Investigator Jose Santana from Community Care Licensing Division’s Investigation’s Branch (CCLD IB) conducted the investigation.

Continued LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Desaree PereraTELEPHONE: (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.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 31-AS-20190830120316
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: 10/21/2020
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On 09/06/2019, 09/11/2019, 09/17/2019, 09/18/2019, 09/26/2019, 10/11/2019, 12/02/2019 and 12/11/2019, IB Investigator Santana conducted interview with facility staff. On 09/06/2019, 09/17/2019, 09/18/2019, and 10/19/2019, Investigator Santana conducted interviews with facility residents and family/responsible parties. Additionally, on 09/09/2019, 09/11/2019, 10/11/2019, and 01/27/2020, Investigator Santana conducted interviews with other relevant parties, including but not limited to, the Lost Hill Sheriff’s Department staff, Long Term Care Ombudsman (LTCO) and medical professionals. Moreover, video surveillance footage and records relevant to the allegations were obtained and reviewed by Investigator Santana on 09/25/2019 and 07/28/2020.

Information gathered revealed R2’s pre-admission/initial Comprehensive Assessment dated 03/20/2018 listed a diagnosis of dementia with behavioral disturbance, psychosis, and osteoarthritis of the knees, hands, and feet with a prior elbow fracture. Moreover, a review of Nursing Progress notes reflected on 08/18/2019 that facility staff noted discoloration to R2’s hand, which was after R1 and R2 were found in the bedroom. Staff placed an ice pack on R2’s hand and informed R2’s PCP of the incident. Per PCP orders, a STAT x-ray was ordered for R2’s hand to rule out a fracture and it was revealed that R2 sustained a scaphoid (wrist) bone fracture of the left hand. Although the information gathered revealed that staff only noticed discoloration/bruising of R2’s hand after the incident, staff were unable to confirm if R2 had any bruise/discoloration the morning of, prior to the incident. Based on all information gathered, the Department does not have sufficient evidence to determine R2 sustained a broken hand during the incident; therefore, the above allegation “Resident #2 (R2) sustained a broken hand due to abuse” is deemed UNSUBSTANATIED at this time.

Exit interview conducted/ No citations issued/ a copy of report sent via email for signature.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Desaree PereraTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 6 of 6