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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609117
Report Date: 04/19/2022
Date Signed: 04/19/2022 01:07:19 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
04/12/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20220412150231
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:
04/19/2022
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Esther Chico-GutierrezTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility staff failed to meet resident's hygiene needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for an initial complaint visit. The LPA met with Esther Chico-Gutierrez and explained the reason for the visit.

During today’s visit, the LPA interviewed staff at 9:35 a.m., 10:00 a.m., 10:45 am., and 11:35 a.m.; and reviewed records from 10:20 a.m. – 10:35 a.m.

Regarding the allegation: Facility staff failed to meet resident's hygiene needs.
It was alleged that Resident #1’s (R1) hygiene needs were neglected, as R1 was found with mucus covering their clothing and face, and their overall appearance was unclean. Interviews and video surveillance supported claims that on 4/10/2022, R1 was observed sitting on a bench in the facility with their nose running, and a large amount of mucus had accumulated on R1’s clothing and the facility bench.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
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 29-AS-20220412150231
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: 04/19/2022
NARRATIVE
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Staff were alerted to R1’s appearance, yet it appeared that R1 had been sitting there for an undetermined amount of time. R1’s care plan revealed that R1 requires assistance with grooming and hygiene needs. Based on the information obtained during the course of the investigation, the allegation ‘facility staff failed to meet resident’s hygiene needs’ is Substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

Exit interview conducted. A copy of the report, and appeal rights, were provided.

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

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20220412150231
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: 04/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
04/22/2022
Section Cited
CCR
87464(f)(4)
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87464(f)(4) Basic Services. Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing...
This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Submit a Plan of Action, indicating how the facility will maintain compliance with ensuring that residents are regularly observed and hygiene needs are met for all residents. Submit the Plan of Action to CCL no later than 4/22/2022.
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Based on the investigation, the licensee did not comply with the section cited above as R1's hygiene needs were not met, 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: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC9099 (FAS) - (06/04)
Page: 3 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
04/12/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20220412150231

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:
04/19/2022
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Esther Chico-GutierrezTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff failed to safeguard resident's personal belongings
Staff neglected resident while in care
Facility is not following proper protocol for COVID-19
Facility is not following the visitation protocol
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for an initial complaint visit. The LPA met with Esther Chico-Gutierrez and explained the reason for the visit.

During today’s visit, the LPA interviewed staff at 9:35 a.m., 10:00 a.m., 10:45 am., and 11:35 a.m.; and reviewed records from 10:20 a.m. – 10:35 a.m.

Regarding the allegation: Staff failed to safeguard resident's personal belongings
It was alleged that R1 was moved out of their room temporarily and upon moving R1’s room, R1’s items had been displaced. Interviews explained that in March 2022, the facility experienced a COVID-19 outbreak. R1’s room was located in the area that was designated for the COVID-19 positive residents and as a result, R1 was temporarily relocated. In fact, R1 was temporarily placed in two separate rooms due to the zoning of COVID-19 positive residents.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20220412150231
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: 04/19/2022
NARRATIVE
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Interviews revealed when R1 was temporarily relocated, R1’s clothing, furniture, and some personal items were placed in the temporary rooms. During that time, it appeared that some of R1’s items went missing.

In addition, staff admitted that they believed that R1 was better suited for a different location in the facility due to their care needs. During this time, staff questioned whether R1 would be moved to a different room after the facility was cleared of the COVID-19 outbreak. However, additional discussion was had with R1’s responsible party and facility management regarding a suitable location for R1. At this time, R1 is currently residing in their original room. In addition, interviews confirmed that R1’s personal belongings have been located and returned to R1’s room. Based on the information obtained, there is insufficient evidence to support the claim that staff failed to safeguard resident’s personal belongings. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Staff neglected resident while in care
It was alleged that Resident #2 (R2) is often found on the floor, and that staff were neglecting R2’s needs. Interviews confirmed that R2 oftentimes places themselves on the floor and that it was a reoccurring behavior for R2. Staff stated that they make attempts to assist R2 and move R2 to a more appropriate location, yet staff claim that R2 will place themselves back on the floor. The LPA reviewed R2’s care plans and identified that this behavior is notated on the care plan and that R2’s responsible party is aware. Staff recognize that although they clean and vacuum the facility that the flooring can appear unsanitary due to persons walking throughout the community. As such, staff claim that they want to ensure that R2’s personal rights are respected but also try to assist R2 to a more appropriate location as needed. Based on the information obtained during the course of the investigation, there is insufficient evidence to support the claim that staff neglected resident while in care. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Facility is not following proper protocol for COVID-19
It was alleged that R1 was hospitalized on 2/8/2022 and while in the hospital, was diagnosed with COVID-19. It was also noted that R1 was accompanied by facility staff and further alleged that because the staff was exposed to R1, the staff should have not returned to work. Interviews and records review revealed that R1 was accompanied to the hospital by Staff #1 (S1). Hospital discharge paperwork revealed that R1 tested positive for COVID-19, however, R1 was asymptomatic. Information obtained from an interview with S1 revealed that they were unaware that R1 was COVID-19 positive when they left the hospital.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20220412150231
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: 04/19/2022
NARRATIVE
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 During that time, the facility was undergoing response-testing and S1 was tested for COVID-19. It was confirmed that S1 did not test positive for COVID-19 during the months of January-April 2022, S1 did not display any symptoms after going to the hospital with R1, and S1 was fully vaccinated at the time the incident occurred. Per the Provider Information Notice (PIN) 21-23 issued to facilities on 4/20/2021, “Fully vaccinated facility staff who are asymptomatic do not need to be restricted from work for 14 days following an exposure to COVID-19, per updated Centers for Disease Control and Prevention (CDC) guidance.”

Based on the information obtained during the course of the investigation, there is insufficient evidence to support the claim that the facility did not follow proper protocol for COVID-19. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Facility is not following the visitation protocol
It was alleged that the facility was not following the visitation protocol. Interviews revealed that the facility preferred have outdoor visitation as it poses a lower risk of transmission. However, staff stated that indoor visitation was allowed if the resident’s visitor was either vaccinated or had evidence of a negative COVID-19 test within one day of visitation for antigen tests, or within two days of visitation with a PCR test. Staff stated that if there were repeat visitors that preferred to have indoor visitation, they ensured that all visitors followed protocol as communicated by the local health department and Community Care Licensing. Staff mentioned that most visitors are comfortable with outdoor visitation but stated that indoor visitation was not denied.

Staff stated that when the facility had a COVID-19 outbreak, they had separate outdoor visitation areas for residents whom resided in the Red Zone (positive residents), Yellow Zone (exposed residents, awaiting results), and Green Zone. Staff also shared that for those who were unable to leave the room or that fell under essential visitors, residents were allowed indoor visitation. Staff communicated that they understood the parameters for allowing indoor visitation, especially for visitors in critical condition. Staff denied claims that residents were denied visitation per protocol. Based on the information obtained during the course of the investigation, there is insufficient evidence to support the claim that the facility is not following the visitation protocol. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

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

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6