197609117-1-25-2021-29-AS-JAPL-BXV9NX-20210202223149

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609117
Report Date: 01/25/2021
Date Signed: 01/25/2021 11:49:18 AM

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
01/04/2021 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20210104155928

FACILITY NAME:	SILVERADO SENIOR LIVING - CALABASAS		FACILITY NUMBER:	197609117
ADMINISTRATOR:	GIUNTO, TAYLOR		FACILITY TYPE:	740
ADDRESS:	25100 CALABASAS RD		TELEPHONE:	(818) 222-1000
CITY:	CALABASAS	STATE: CA	ZIP CODE:	91302
CAPACITY:	110	CENSUS: 62	DATE:	01/25/2021
		UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Taylor Giunto		TIME COMPLETED:	11:25 AM

ALLEGATION(S):

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Resident was assaulted by another resident resulting in injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Smith conducted a subsequent complaint inspection to deliver the findings for the above allegation. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s investigation was conducted virtually via FaceTime with Executive Director Taylor Giunto.

During a 1/7/2021, the LPA interviewed staff at 2:36pm, 2:50pm, 3:53pm and 3:56pm; and, interviewed Resident #1 (R1) at 3:02pm. Additional interviews were conducted with staff on 1/19/2021 at 2:23pm, 2:35pm and 2:56pm; and, staff interviews were conducted on 1/22/2021 at 1:57pm, 2:46pm, 3:01pm, and 3:17pm.

CONT 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210104155928

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: 01/25/2021

NARRATIVE

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It was alleged that due to lack of supervision, Resident #1 (R1) was assaulted by Resident #2 (R2) on 12/15/2020, resulting in injury. Witness interviews revealed that on 12/15/2020, staff heard a noise in R1’s room, and immediately responded. Upon review, staff observed R1 on the floor and after assessment, observed an abrasion on R1’s head. Thereafter, the residents were separated and put on regular status checks. Interviews further disclosed that within a half hour, the two residents allegedly approached each other, shook hands, and apologized to one another. The incident was unwitnessed; thus, staff were unable to disclose how R1 sustained an injury to the head.

Staff interviews and a review of Facility Progress Notes regarding R1 confirmed that staff regularly checked on R1 to assess for a change of condition and/or pain, and administered pain medication when requested. At the request of R1’s family, x-rays were conducted, and no fractures or injuries were discovered as a result of the incident. Staff did not observe any additional change of condition with R1. There is no evidence or documentation to support that as a result of the incident, R1 or R2 experienced additional injury. The LPA spoke with R1 on 1/7/2021, yet R1 could not recall details of the incident and stated that everyone at the facility treated them with dignity and respect. The LPA was unable to speak to R2.

Interviews and records review revealed that the incident on 12/15/2020 appeared to be an isolated incident, as R1 and R2 do not present as a threat to anyone within the facility. A review of care plans revealed that neither resident required 1:1 supervision at the time of the incident. As it appeared that this was an isolated incident, care plans were not updated to increase supervision for either resident. Interviews conducted revealed that the facility is entirely memory care and primarily accepts residents diagnosed with dementia, and the facility structure allows for residents to walk throughout the facility without restriction. It was confirmed that residents often wander into other resident rooms. However, it is hard to predict resident behaviors and certain triggers.

Based on the information gathered, there is insufficient evidence to support the claim that due to lack of supervision, R1 was assaulted by R2. The above allegation is deemed Unsubstantiated at this time.

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

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021

LIC9099 (FAS) - (06/04)

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