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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609117
Report Date: 08/01/2023
Date Signed: 08/01/2023 02:58:54 PM


Document Has Been Signed on 08/01/2023 02:58 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: 57DATE:
08/01/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Terri WeitzmanTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management / Non-Compliance visit 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. The LPA met with Terri Weitzman and explained the reason for the visit. The last legal/non-compliance visit was conducted on 05/22/2023.

The LPA and Executive Director toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations.

There were no obstructions and/or tripping hazards throughout the facility. The facility maintains a comfortable temperature. Fire extinguishers were charged and last serviced within the past twelve (12) months. Planned activities are offered. Activity rooms and common spaces appeared clean and in good repair. The facility has several enclosed courtyards with appropriate outdoor seating for resident use. The swimming pool on the premises was observed to be locked.

RESIDENT ROOMS: The LPA and Executive Director observed eight (8) rooms, and rooms were furnished with clean linens, furnishings and lighting. Restrooms were observed with properly installed grab-bars in resident bathrooms and non-skid strips in shower tubs. At 12:34 p.m., the LPA observed a basket of personal care items and razors in Room 53. At 12:40 p.m., personal care items were in Room 67. At 12:47 p.m., personal care items were observed in Room 17.

FILES: From 12:45 p.m. – 1:10 p.m., the LPA reviewed the files of the three (3) resident that had personal care and hygiene items accessible in their rooms. Out of the three (3) files reviewed, the LPA reviewed physician’s reports and identified that there was one (1) resident (Resident #1 – R1) that was deemed at risk if they have access to personal care items. All three residents had a diagnosis of Dementia.

CONT 809-C

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023
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: 08/01/2023
NARRATIVE
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MEDICATION AUDIT: From 1:20 p.m. – 2:10 p.m., a medication audit was conducted for three (3) residents. The following was noted:

- Resident #2 had an as-needed (PRN) medication for acetaminophen that was administered two (2) times; however, staff only documented that R2 was assisted with the self-administration of this PRN medication one (1) time.


- Resident #3 had a PRN medication for acetaminophen that was administered seven (7) times since August 2022; however, there was no documentation to confirm the dates and times that R3 was assisted with the self-administration of this as-needed medication.

INCIDENT REPORTS: The LPA reviewed incident reports pertaining to Resident #4 (R4). On 06/01/2023 and 7/2/2023, R4 left the facility unassisted. During the 06/01/2023 incident, R4 was noted outdoors outside the community back patio, behind the fence, sitting on a hill. R4 was escorted back into the facility without any notable injuries. During the 7/2/2023 incident, staff noted that a window was broken in a resident room. After completing a resident count, staff observed that R4 was not in the community. Staff canvassed the surrounding areas and R4 was located by the Administrator. R4 was noted to have skin tears. Emergency services were called and R4 was hospitalized. After this incident, an in-service training on Elopement Protocols and Procedures was held. R4’s physician’s report confirmed that R4 is not able to leave the facility unassisted. On two separate occasions, R4 was able to leave the facility, unbeknownst to staff. R4 is currently out of the facility at this time due to a medical-related issue.

LEGAL: On 6/29/2023, licensee has requested a reduction in the frequency of calls with CareerSmart. Per the stipulation, the licensee must have weekly calls with CareerSmart. Licensee is requesting for weekly calls to take place either bi-weekly or once a month. Approval from the Department is pending 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 809-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued via email. Signatures were obtained.

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

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/01/2023 02:58 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: 08/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/01/2023
Section Cited
CCR
87705(f)(1)

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87705(f)(1) Care of Persons with Dementia. (f) The following shall be stored inaccessible... Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Secured the items upon observation. POC is cleared at this time.
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Based on observation, the licensee did not comply with the section cited above, as razors were observed accessible in Room 53, which poses an immediate health and safety risk to residents in care.
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Deficiency Dismissed
Type A
08/01/2023
Section Cited
CCR87705(g)(1)

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87705(g)(1) Care of Persons with Dementia. … Residents with dementia shall be allowed to keep personal grooming and hygiene items … unless there is evidence to substantiate that the resident cannot safely manage the items.
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The Administrator agreed to the following:
1. Secure the items by the end of the day. Inform CCL when this has taken place
2. Conduct an in-service training with care staff, regarding items that shall be inaccessible to residents with dementia.
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This requirement is not met as evidenced by:
Based on observation and record review, the licensee did not comply in the section cited above for one out of three residents (R1), which poses an immediate health and safety risk to residents in care.
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Submit sign-in sheet no later than 8/11/2023. Submit POC to CCLASCPWoodlandHillRO@dss.ca.gov, ATTN: Officer of the Day
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: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 08/01/2023 02:58 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: 08/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/02/2023
Section Cited
CCR
87464(f)(1)

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87464(f)(1) Basic Services. 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:
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The Administrator has agreed to do the following:
1. The facility has also reviewed and held an in-service training regarding Elopement procedures. Plan of Correction met.
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Based on interview and records review, the licensee did not comply with the section cited above, as the facility failed to ensure that R4 did not leave the facility unassisted per the physician report, which poses an immediate health and safety risk to residents in care.
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Type A
08/02/2023
Section Cited
CCR87465(d)(3)

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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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The Administrator has agreed to do the following:
1. Host an in-service training, discussing topics that include but are not limited to: PRN documentation, checking centrally stored forms for accuracy.
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Based on medication review, the licensee did not comply in the section cited above for 2 out of 3 (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 8/2/2023. Training for all must be completed by 8/11/2023
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: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4