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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609117
Report Date: 03/26/2025
Date Signed: 03/26/2025 10:44:14 AM

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
10/15/2024 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20241015100719
FACILITY NAME:SILVERADO SENIOR LIVING - CALABASASFACILITY NUMBER:
197609117
ADMINISTRATOR:KEITH PAYNEFACILITY TYPE:
740
ADDRESS:25100 CALABASAS RDTELEPHONE:
(818) 222-1000
CITY:CALABASASSTATE: CAZIP CODE:
91302
CAPACITY:110CENSUS: 48DATE:
03/26/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Patrice O'GradyTIME COMPLETED:
10:50 AM
ALLEGATION(S):
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Neglect/Lack of Care led to Questionable Death
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kelly Dulek and Quoc Huynh conducted a subsequent complaint investigation regarding the above noted allegation. LPAs were greeted by front desk staff. LPAs met with Administrator Patrice O’Grady at 10:18AM and explained the reason for the visit. Entrance interview conducted.

During an initial complaint visit conducted on 10/16/2024, LPA Dulek interviewed Interim Administrator Laken Lacy at 10:06AM related to recent incident reports and death reports submitted to the Department, reviewed and obtained copies of relevant documents. LPA, along with Interim Administrator and pending Administrator Patrice O'Grady, conducted a health and safety check tour of the facility at 11:05AM. No immediate health and safety hazards were observed during facility tour. LPA informed Interim Administrator that the allegation was referred to Community Care Licensing Division (CCLD)'s Investigations Branch (IB) and assigned to IB Investigator Laura Garcia. Investigator Garcia conducted both telephonic and in person interviews with staff
Report Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
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 5
Control Number 29-AS-20241015100719
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: 03/26/2025
NARRATIVE
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and other relevant parties on the following dates: 10/16/2024,10/18/2024, 10/19/2024, 11/07/2024, 11/11/2024, 02/26/2025, 02/27/2025, and 03/04/2025. Investigator Garcia also reviewed medical records for Resident #1 (R1). LPA Dulek reviewed information obtained from all sources. The following was then determined:
The complaint alleges that while being transferred using a Hoyer lift, R1 fell, causing a brain hemorrhage, resulting in R1’s death. An incident report was submitted to the Woodland Hills Regional Office on 09/03/2024 indicating R1 fell while Staff #1 (S1) was attempting to transfer R1 while using a Hoyer Lift. Staff interviews and documents reviewed indicate that R1 was a high fall risk and R1 required a 2-person transfer assist. Care Plan and Silverado policy states “Transfers – 2-person assist. Provide resident with 2-person physical assist to increase independence and ensure safety in transfers.” However, S1 admitted that although they were aware of Silverado policy and R1’s care plan, S1 did not call for assistance transferring R1 on the morning of 08/30/2024. As S1 pulled the lift back with the sling attached and R1 in the sling, S1 lost control of the lift and the lift tilted to one side. S1 admitted that due to S1’s stature and R1’s weight, S1 could not regain control of the lift, resulting in the lift falling, R1 hitting their head on the floor and causing a head injury. S1 called for assistance from the facility LVN on duty. R1 was assessed for injury and noted to be awake, but had a blank stare, was unresponsive to light and not blinking. 9-1-1 was called and R1 was taken to the hospital for further medical treatment. R1 was admitted to the hospital in critical care due to the head injury sustained at the facility. R1 was diagnosed with a subdural hematoma measuring 6 mm in maximal depth with a 2 mm midline shift to the left. R1 was discharged from the hospital to a Skilled Nursing Facility before returning to Silverado Senior Living Calabasas on 10/01/2024. R1 was admitted to hospice on the date of their return. R1 passed away under hospice care on 10/03/2024. Immediate cause of death listed on Certificate of Death was Traumatic Subdural Hematoma. Manner of death was listed as accidental as a result of injury sustained due to “fall in hospice facility” on 08/30/2024. Based on interview and record review, the preponderance of evidence standard has been, therefore the allegation “neglect/lack of care leading to questionable death” is deemed SUBSTANTIATED at this time.

A $500 immediate civil penalty is assessed today. The Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and/or 1569.49(f).

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency is cited (refer to LIC9099-D).

Exit interview conducted, appeal rights discussed, and a copy of this report was provided.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20241015100719
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: 03/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/26/2025
Section Cited
CCR
87464(f)(4)
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87464 Basic Services (f) (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 and assistance with taking...Postural Supports
This requirement is not met as evidenced by:
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Administrator stated Hoyer lift training was completed immediately following the incident, and additional vendored training was also provided. Disciplinary action involving S1 has been completed. Administrator provided documentation of trainings and disciplinary action completed, POC cleared.
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Based on interview and record review, the licensee did not comply with the above cited section as S1 did not transfer R1 per R1's care plan, which resulted in R1 falling, sustaining injury, and R1 passed away as a result, which posed an immediate health and safety risk to persons 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
10/15/2024 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20241015100719

FACILITY NAME:SILVERADO SENIOR LIVING - CALABASASFACILITY NUMBER:
197609117
ADMINISTRATOR:KEITH PAYNEFACILITY TYPE:
740
ADDRESS:25100 CALABASAS RDTELEPHONE:
(818) 222-1000
CITY:CALABASASSTATE: CAZIP CODE:
91302
CAPACITY:110CENSUS: 48DATE:
03/26/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Patrice O'GradyTIME COMPLETED:
10:50 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Neglect/Lack of Care – inadequate staffing to transfer resident in care, resulting in resident falling
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Kelly Dulek and Quoc Huynh conducted a subsequent complaint investigation regarding the above noted allegation. LPAs were greeted by front desk staff. LPAs met with Administrator Patrice O’Grady at 10:18AM and explained the reason for the visit. Entrance interview conducted.

During an initial complaint visit conducted on 10/16/2024, LPA Dulek interviewed Interim Administrator Laken Lacy at 10:06AM related to recent incident reports and death reports submitted to the Department, reviewed and obtained copies of relevant documents. LPA, along with Interim Administrator and pending Administrator Patrice O'Grady, conducted a health and safety check tour of the facility at 11:05AM. No immediate health and safety hazards were observed during facility tour. LPA informed Interim Administrator that the allegation was referred to Community Care Licensing Division (CCLD)'s Investigations Branch (IB) and assigned to IB Investigator Laura Garcia. Investigator Garcia conducted both telephonic and in person interviews with staff
Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
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 5
Control Number 29-AS-20241015100719
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: 03/26/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
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25
26
27
28
29
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32
and other relevant parties on the following dates: 10/16/2024,10/18/2024, 10/19/2024, 11/07/2024, 11/11/2024, 02/26/2025, 02/27/2025, and 03/04/2025. Investigator Garcia also reviewed medical records for Resident #1 (R1). LPA Dulek reviewed information obtained from all sources. The following was then determined:

The complaint alleges that inadequate staffing led to R1 falling during transfer, resulting in injury. An incident report was submitted to the Woodland Hills Regional Office on 09/03/2024 indicating R1 fell while Staff #1 (S1) was attempting to transfer R1 while using a Hoyer Lift. Staff interviews and documents reviewed indicate that R1 was a high fall risk and R1 required a 2-person transfer assist. Although S1 was aware of both Silverado policy and R1’s care plan, on the morning of 08/30/2024, S1 chose to transfer R1 alone. S1 stated they believed other staff to be busy assisting other residents at that time and S1 did not wish to “bother them.” S1 admitted they made a mistake and should have called for a second staff to assist with the transfer. Interviews and staff schedule review indicate at the time of the incident, there were 6 total care staff, 1 (one) LVN, and 1 (one) medication technician present at the facility on the date of the incident. The census on 08/30/2024 was 52 residents. At the time of the incident, 5 (five) caregivers were each assigned to care for their own specific group of residents and the additional caregiver was working as a floater, to assist with 2-person transfers and assist as needed with residents. S1 admitted they do have the ability to call for assistance, but on the date of the incident S1 did not request assistance. Management staff did “write up” S1 as a result of the policy violation. Based on the information obtained during the investigation there is insufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation “neglect/lack of supervision – inadequate staffing to transfer resident in care, resulting in resident falling” is deemed UNSUBSTANTIATED at this time.

No citations issued related to the above allegation. Exit interview conducted. A copy of today’s report was provided.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5