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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320131
Report Date: 01/26/2024
Date Signed: 01/26/2024 06:31:34 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/03/2023 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20231103154508
FACILITY NAME:SILVERADO ROLLING HILLSFACILITY NUMBER:
198320131
ADMINISTRATOR:LOURDES MENCHACAFACILITY TYPE:
740
ADDRESS:2455 PACIFIC COAST HWYTELEPHONE:
(424) 488-0593
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:68CENSUS: 39DATE:
01/26/2024
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Olivia BlaylockTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not administer medications to resident
Staff left resident in soiled diapers
INVESTIGATION FINDINGS:
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On 01/26/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a subsequent complaint visit to the facility listed above. During today's visit LPA met with Executive Director, Olivia Blaylock, and the purpose of today’s visit was explained.

During today’s visit, LPA toured the facility, interviewed Residents (R5-R8), and received a resident incontinent list. During a previous visit on 11/09/23, LPA toured the facility, interviewed Staff (S1-S6) and Residents (R2-R4), and received documents pertinent to the complaint. LPA reviewed and received the following documents: Staff Roster, Resident Roster, resident Shower Schedule, Physician’s Report, Physician’s Orders, Pre-Appraisal, Needs and Service Plan, Centrally Stored Medications, MARs, Staff/Nurse Notes, and Incident Reports.

The investigation reviewed the following:

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
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 8
Control Number 11-AS-20231103154508
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SILVERADO ROLLING HILLS
FACILITY NUMBER: 198320131
VISIT DATE: 01/26/2024
NARRATIVE
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Allegation: Staff did not administer medications to resident.

The allegation alleges that a resident did not get their medications because the facility did not know where the resident’s medications were.

LPA reviewed Resident R1’s Centrally Stored Medication and their electronic Medication Administration Record (eMAR), LPA observed on the date of 08/12/23 one medication was marked “Drug Not Given (DNG)” and the other medication on that date was not marked. Additionally, on 08/13/23 the same medication was marked “Drug Not Available (DNA)” and the other medication on that date was marked DNG. During an interview with W1, stated they came in to visit R1 on 08/13/23 and the nurse, from an outside vendor, that was working couldn’t find R1’s medications. Additionally, W1 stated R1 was not given their medications till 08/15/23 when the regular nurse returned.

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 11-AS-20231103154508
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SILVERADO ROLLING HILLS
FACILITY NUMBER: 198320131
VISIT DATE: 01/26/2024
NARRATIVE
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Allegation: Staff left resident in soiled diapers.

The allegation alleges that on dates while family was visiting, the resident was not changed for hours and was left in soiled diapers.

During interviews with Resident’s (R1, R6, and R7) Responsible Party W1, W2, and W3, three (3) out of three (3), stated they have had issues, in the past, with their Resident’s (R1, R6, and R7) being left in a soiled diaper for an extended period of time. W1 stated that during a visit on 08/15/23, no staff came to check to see if R1 needed changed from 11:30am till 5:30pm, and the family did it themselves. Additionally, W1 stated on 08/16/23, family was there from 10:30am till 6:30pm and no staff came to check if R1 needed changed and they had to go ask staff twice to come and change R1. During an interview with W2, stated there were times in September and August 2023 when they would come to visit R6 at 9am and R6 was really wet and in the same diaper from the night before. During an interview with W3, stated that when R7 first moved-in, in August 2023, R7 was in soiled diapers when W3 came to visit.


Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D.

An exit interview was conducted with Executive Director, Olivia Blaylock, and a copy of this report

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 11-AS-20231103154508
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SILVERADO ROLLING HILLS
FACILITY NUMBER: 198320131
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
02/09/2024
Section Cited
CCR
87625(b)(3)
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87625Managed Incontinence(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(3)Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
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Administrator will train staff and review Title 22 regulations regarding Managed Incontinence with staff and send signed training to LPA by POC.
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This regulation was not met, based on interviews conducted Resident's R1 and R6 Responsible Parties, R1 and R6 were observed multiple times being left in soilded diapers for an extended period of time.
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Type B
02/09/2024
Section Cited
CCR
87565(c)(2)
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87465Incidental Medical and Dental Care(c)If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee
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Administrator will train staff and review Title 22 regulations regarding Inicdental Medical and Dental Care with staff and send signed training to LPA by POC.
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shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:2)Once ordered by the physician the medication is given according to the physician's directions.
This regulation was not bet based on file
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review and interview, Resident R1 did not recieve their medication on 08/12/23 and 08/13/23 and was marked not giving and not available.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/03/2023 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20231103154508

FACILITY NAME:SILVERADO ROLLING HILLSFACILITY NUMBER:
198320131
ADMINISTRATOR:LOURDES MENCHACAFACILITY TYPE:
740
ADDRESS:2455 PACIFIC COAST HWYTELEPHONE:
(424) 488-0593
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:68CENSUS: 39DATE:
01/26/2024
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Olivia BlaylockTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
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5
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9
Staff did not shower resident
Due to staff negligence, resident had several unwitnessed falls
Staff did not provide timely medical care for resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 01/26/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a subsequent complaint visit to the facility listed above. During today's visit LPA met with Executive Director, Olivia Blaylock, and the purpose of today’s visit was explained.

During today’s visit, LPA toured the facility, interviewed Residents (R5-R8), and received a resident incontinent list. During a previous visit on 11/09/23, LPA toured the facility, interviewed Staff (S1-S6) and Residents (R2-R4), and received documents pertinent to the complaint. LPA reviewed and received the following documents: Staff Roster, Resident Roster, resident Shower Schedule, Physician’s Report, Physician’s Orders, Pre-Appraisal, Needs and Service Plan, Centrally Stored Medications, MARs, Staff/Nurse Notes, and Incident Reports.

The investigation reviewed the following:

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 11-AS-20231103154508
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SILVERADO ROLLING HILLS
FACILITY NUMBER: 198320131
VISIT DATE: 01/26/2024
NARRATIVE
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Allegation: Staff did not shower resident.

The allegation alleges that the family visited the resident, and they hadn’t been showered.

LPA reviewed the facilities shower logs for August, September, October, and November, LPA observed what residents were assisted with showers and on which day. During interviews with Staff (S1-S5) five (5) out of five (5) stated residents who require assistance with bathing are assisted 2 to 3 times a week. Additionally, Staff S1-S3 stated the Residents have the right to refuse a shower and they cannot force a resident to shower. During interviews with Resident’s (R1, R6, and R7) Responsible Party W1, W2, and W3, two (2) out of three (3), stated their Resident’s (R6, and R7) receive assistance with bathing 2 to three times a week. During an interview with W1 they stated they had gone to the facility on R1’s scheduled shower days and R1 was not given a shower until later in the day when W1 went and asked if anyone was coming to assist R1 with a shower.

During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the above allegation did or did not occur, therefore the allegation is unsubstantiated.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 11-AS-20231103154508
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SILVERADO ROLLING HILLS
FACILITY NUMBER: 198320131
VISIT DATE: 01/26/2024
NARRATIVE
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Allegation: Due to staff negligence resident had several unwitnessed falls.

The allegation alleges that resident had multiple falls and the staff could not state what happened.

During interviews with Staff (S1-S5), five (5) out of five (5) stated that for resident who are a fall risk have additional procedures to help ensure the safety of those residents. Five (5) out of five (5) Staff (S1-S5), stated residents who are a fall risk are checked every hour, provided tag alarms, offered high/low beds, fall mats, and hip protectors, which are optional). During an interview with W1, they stated Resident R1 had multiple unwitnessed falls, and nobody could tell W1 how the fall occurred. LPA reviewed the facilities Special Incident Reports (SIR) and LPA observed two (2) of the three (3) falls were observed by staff and assistance was provided immediately. During interviews with Residents (R2-R8) seven (7) out of seven (7) stated they do not have concerns regarding staff’s extra preventions taken to help reduce falls.

During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the above allegation did or did not occur, therefore the allegation is unsubstantiated.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 11-AS-20231103154508
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SILVERADO ROLLING HILLS
FACILITY NUMBER: 198320131
VISIT DATE: 01/26/2024
NARRATIVE
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Allegation: Staff did not provide timely medical care for resident.

The allegation alleges that the family came to visit a resident and found the client in a condition requiring medical care.

During interviews with Staff (S1-S5) five (5) out of five (5) stated there is a nurse on site 24-hours a day to provide medical care to residents, and if additional care is required the Resident will be transported to the Emergency Room for further evaluation. During interviews with Residents (R2-R8) seven (7) out of seven (7) stated they receive medical treatment within a timely manner. During review of Special Incident Reports (SIR) for R1 on 08/26/23, stated R1 was being treated by the facility nurse when the W1 arrived. The nurse recommended that R1 go to the Emergency Room for further evaluation and W1 said they would take R1.

During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the above allegation did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted with Executive Director, Olivia Blaylock, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 8