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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609117
Report Date: 05/22/2023
Date Signed: 05/22/2023 02:39:34 PM


Document Has Been Signed on 05/22/2023 02:39 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: 55DATE:
05/22/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Terri Weitzman and Kaitlyn SmithTIME COMPLETED:
02:45 PM
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
Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced required annual visit. Along with the required annual visit, 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 Kaitlyn Smith and explained the reason for the visit. The last legal/non-compliance visit was conducted on 2/1/2023.

Today, the LPA conducted a file review for five (5) residents and five (5) staff. A file review of five (5) resident files was conducted from 12:30 p.m. – 1:30 p.m. Files were reviewed for, but not limited to: admissions agreements, medical assessment, updated appraisals, consent forms. Resident records were in order.

A file review of five (5) staff files was conducted from 1:30 p.m. – 2:30 p.m. Files were reviewed for, but not limited to: job application, health assessments, TB results, criminal record statements and clearances, first aid certification. Out of the five files reviewed, the following was observed: Staff #1 and Staff #2 did not have a completed job application, medical assessment, or criminal record statement on file, and Staff #3 did not have tuberculosis results on file.

LEGAL: As it pertains to the Stipulation and Waiver, and Order, the following was noted:


· Career Smart conducting quarterly audits: The last audit took place in March 2023; recommendations were made around organization of staff training and the availability of care plans
· Compliance audit was conducted by a member of the licensee’s governing board on 02/27/2023
· Facility continues to monitor staffing levels as it relates to resident care needs and census.
· Staff support group was conducted on 4/28/2023; staff encouraged to obtain the total attendance
· Resident care needs are assessed monthly

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: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 05/22/2023 02:39 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: 05/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
05/31/2023
Section Cited
CCR
87411(f)

1
2
3
4
5
6
7
87411(f) Personnel Requirements – General. … Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician ....
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Administrator agreed to do the following:
1. Obtain the completed health screenings and/or TB results for S1, S2 and S3. Submit proof by 5/31/2023
8
9
10
11
12
13
14
Based on file review, the licensee did not comply to the section cited above for three out of five staff (S1, S2, S3), which poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
Deficiency Dismissed
Type B
05/31/2023
Section Cited
CCR87355(d)

1
2
3
4
5
6
7
87355(d) Criminal Record Clearance. All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Administrator agreed to do the following:
1. Obtain the completed criminal record statements for S1 and S2. Submit proof by 5/31/2023
8
9
10
11
12
13
14
Based on file review, the licensee did not comply to the section cited above for two out of five staff (S1, S2), which poses a potential 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: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2