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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609117
Report Date: 11/01/2022
Date Signed: 11/01/2022 02:52:32 PM


Document Has Been Signed on 11/01/2022 02:52 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:TERRI WEITZMANFACILITY TYPE:
740
ADDRESS:25100 CALABASAS RDTELEPHONE:
(818) 222-1000
CITY:CALABASASSTATE: CAZIP CODE:
91302
CAPACITY:110CENSUS: 53DATE:
11/01/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Vida Gwinn, Selene Rangel, Terri WeitzmanTIME COMPLETED:
03:00 PM
NARRATIVE
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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:
- Career Smart conducting quarterly audits: The last audit took place in September from 9/6 – 9/8.
- On site visits from a member of the governing board: The last visit was August; the next date is 11/18/2022.
- Monthly support groups for staff – The last session took place on 10/25/2022.
- Additional training hours - The facility requires the staff to complete the hours on a monthly basis. The LPA reviewed training documents to confirm that staff are receiving the required training hours.

From 12:35 p.m. – 1:40 p.m., the LPA conducted a medication audit for five (5) residents.
- Resident #1 experienced a medication change on 10/15/2022, in which the order was changed from receiving one capsule three times a day to receiving two capsules two times a day. Whereas the staff claim that the original medication was discontinued and was not administered to R1, staff continued to sign off as if R1 received the initial medication and the new medication dosage.
- Resident #2 had an as-needed medication (Seroquel) that was administered two (2) times; however, staff only documented that R2 was assisted with the self-administration of this as-needed medication one (1) time. R2 had a PRN for acetaminophen that was administered eight (8) times in two months; however, staff documented that R2 was assisted with the self-administration of this as-needed medication three (3) out of eight (8) times.
- Resident #3 had an as-needed medication administered five (5) times in two months; however, staff only documented that R3 was assisted with the self-administration of this as-needed medication three (3) times.

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: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2022
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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Document Has Been Signed on 11/01/2022 02:52 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: 11/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2022
Section Cited

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87465(d)(3) Incidental Medical and Dental Care. The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.
This requirement is not met as evidenced by:
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Based on medication review, the licensee did not comply in the section cited above for three out of five (R1, R2, R3) residents as it pertains to documentation for assisting residents with the self-administration of PRN medication, which poses an immediate health and safety risk to residents in care.
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In-service must include nurses and medication technicians. Submit initial sign-in sheet by 11/04/2022. Training for all must be completed by 11/10/2022.

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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: 11/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2022
LIC809 (FAS) - (06/04)
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