198320131-11-5-2024-11-AS-EMAZ-DBY5KJ-20241214190138

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320131
Report Date: 11/05/2024
Date Signed: 11/05/2024 04:40:38 PM

Unsubstantiated

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
10/28/2024 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20241028134149

FACILITY NAME:	SILVERADO ROLLING HILLS		FACILITY NUMBER:	198320131
ADMINISTRATOR:	SABRINA PEGROSS		FACILITY TYPE:	740
ADDRESS:	2455 PACIFIC COAST HWY		TELEPHONE:	(424) 488-0593
CITY:	TORRANCE	STATE:	ZIP CODE:	90505
CAPACITY:	68	CENSUS: 42	DATE:	11/05/2024
		UNANNOUNCED	TIME BEGAN:	09:08 AM
MET WITH:	Divine Tuzon		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Lack of Supervision resulting in injury to resident in care

INVESTIGATION FINDINGS:

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On 11/05/2024, the department conducted an unannounced complaint visit to the facility listed above. The department met with Director of Health Services, Divine Tuzon, and the purpose of today’s visit was explained.

During today’s visit the department toured the facility, interviewed Staff S1-S9, interviewed Residents R2-R6, interviewed Resident R1’s Responsible Party, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Special Incident Report (SIR), Resident Face Sheet Profile, Physician’s Report, Preplacement Appraisal, Comprehensive Assessment/Observation, Care Conference Sheet, Service Plan Detail, Hospice Documents, Silverado Hospice Communication Update, Resident Progress Notes, and Admission Agreement.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024

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 11-AS-20241028134149

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: 11/05/2024

NARRATIVE

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Allegation: Lack of supervision resulting in injury to resident in care.
Resident had an unwitnessed fall after rounds were done.

During file review, the department observed a Special Incident Report (SIR) was faxed to Community Care Licensing on 11/02/2024, regarding an incident that occurred on 10/28/2024 in regard to R1. The SIR stated R1 was observed on the floor with broken glass around them and bleeding was noted. The department received and reviewed R1’s Service Plan Details dated on 10/24/24 that indicates for Mobility/Ambulation, Escorts, and Transferring resident R1 may require prompts/cues for safety, does not require hands on assistance. Additionally, it indicates resident R1 has experienced a fall on 07/30/24 and was observed on the floor on 08/25/2024 resulting in interventions being put in place to minimize fall risk and decrease injury including Mobility program/physical therapy and hip savers. The department received and reviewed a copy of R1’s hospital discharge paperwork from Torrance Memorial Medical Center that states R1 was seen for an unwitnessed fall and abrasions were observed on R1’s legs.

During interviews with Staff S1-S9, were asked if there is enough staff on each shift to provide proper supervision, nine (9) out of nine (9) stated there is enough staff on each shift for proper supervision.
During interviews with Residents R2-R6, were asked if there are enough staff on each shift to provide supervision to residents, five (5) out of five (5) stated there is enough staff on each shift to provide proper supervision. Additionally, during interviews Residents R2-R6 were asked if they have sustained injuries due to lack of supervision, five (5) out of five (5) stated they have not sustained injuries due to

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20241028134149

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: 11/05/2024

NARRATIVE

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lack of supervision.
During an interview with W1, R1’s responsible person, was asked if they have any concerns with the supervision R1 receives at the facility, W1 stated they have no concerns. Additionally, W1 was asked if they have any concerns regarding the abrasions on R1’s legs, W1 stated R1 has a history of scratching their legs and stomach.

During the investigation, the department did not find sufficient evidence to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard was not met. 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 is unsubstantiated.

No deficiencies were observed or cited during today’s visit.

An exit interview was conducted with Director of Health Services, Divine Tuzon, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024

LIC9099 (FAS) - (06/04)

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