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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320131
Report Date: 04/10/2025
Date Signed: 04/10/2025 04:57:26 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
04/01/2025 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20250401153101
FACILITY NAME:SILVERADO ROLLING HILLSFACILITY NUMBER:
198320131
ADMINISTRATOR:FARID TOMMY TAHERIFACILITY TYPE:
740
ADDRESS:2455 PACIFIC COAST HWYTELEPHONE:
(424) 488-0593
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:68CENSUS: 41DATE:
04/10/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Taylor GiuntoTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Due to neglect, resident sustained pressure injuries
Due to staff neglect, resident was dehydrated
Due to staff neglect, resident had malnutrition
Staff are not following residents special diet
Due to lack of supervision, resident has had multiple falls
INVESTIGATION FINDINGS:
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On 04/10/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced subsequent Complaint Visit to the facility listed above. LPA met with Administrator, Taylor Giunto, and the purpose of today’s visit was explained. LPA was granted entry into the facility.
The investigation consisted of the following:
During today’s visit, LPA inspected the facility, interviewed Residents R2-R7, and interviewed Witnesses W2-W3, and received additional documents.
During the initial visit conducted on 04/09/2025, LPA inspected the facility, interviewed Staff S1-S9, and received documents pertinent to the investigation. The following documents were received and reviewed, Staff Roster, Resident Roster, Plan of Operation, Facility Menu, Admission Agreement, Physician’s Reports, Physician’s Orders, Assessment, Care Plan, Dietary Orders, Charting/Staff Notes, hospital/rehab discharge paperwork, and incident reports.

The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
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 6
Control Number 11-AS-20250401153101
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: 04/10/2025
NARRATIVE
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Allegation: Due to neglect, resident sustained pressure injuries
The allegation alleges that medical professional has concerns of neglect resulting in pressure ulcers.
During the facility inspection, LPA observed a caregiver transferring a resident from their wheelchair to their bed to relieve pressure. LPA observed a pressure cushion on the resident’s chair. The resident stated after activities the staff will assist them to their bed till the next activity or meal.
During file review, LPA received and reviewed resident R1’s Physician’s Report, dated 05/04/2024 that indicates no history of skin breakdown or condition. LPA received and reviewed R1’s Service Plan details dated 12/05/2024, that states Resident’s skin condition is normal, routine skin checks are conducted, and the use of pressure reduction cushions, mattress, boots, lotion, and creams, and assist with repositioning. A routine Wellness Observation was conducted on 02/28/2025, that indicates a full body skin assessment was completed and No lesions/symptoms were noted. Additionally, LPA reviewed Discharge/Transfer Progress Note dated 03/04/2025, that indicates Resident R1’s skin is intact at time of transfer. R1 was out of the facility from 03/04/2025 through 03/28/2025. LPA reviewed staff Progress Notes from 03/28/2025 through 03/31/2025 that indicated on 03/28/2025 at 9:19 PM R1 returned from the hospital and a skin check was performed, no pressure injuries were noted. Resident was kept clean and dry. On 03/29/2025 at 1:09PM, it was noted R1 was transferred from the bed to the wheelchair and then back to bed, and R1 was assisted with repositioning every 2 hours. Staff ensured resident was clean and dry. On 03/29/2025 at 10:32 AM, it was noted R1 was assisted with repositioning every 2 hours. On 03/29/2025 at 3:09PM, it was noted R1 was in bed and repositioned throughout shift, while family was at bedside. On 03/29/2025 at 9:59 PM, it was noted R1 was in bed and assisted with repositioning every 2 hours and was kept clean and dry.
During interviews with Staff S1-S8, were asked if any residents have been diagnosed with pressure injuries due to staff not assisting residents with repositioning, five (5) out of eight (8) stated no residents have sustained a pressure injury due to lack of repositioning.
During interview with Resident R2-R7, were asked if they have gotten any pressure ulcers or sores due to staff not assisting with repositioning, six (6) out of six (6) state stated they have not gotten any sores from not being repositioned and that staff are always available to help them reposition their bodies in bed, in their wheelchair, and even regular chairs.
During interviews with Witnesses W1-W3, were asked if their resident has sustained pressure injuries due to not being assisted with repositioning, two (2) out of three (3) stated they are not sure if the pressure injuries were caused from repositioning. One (1) out of three (3) stated there has been no concerns of pressure injuries.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20250401153101
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: 04/10/2025
NARRATIVE
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Allegation: Due to staff neglect, resident was dehydrated
The allegation alleges resident was exhibiting signs of dehydration.
During the facility inspection, LPA observed water and juice available in the bistro area. Additionally, LPA could periodically hear caregivers ask residents if they want something to drink or reminding them to take a drink of their beverage.
During record review, LPA received and reviewed Resident R1’s Progress notes. On 03/29/2025 at 1:09 PM, it was noted that R1 drank 50% of an ensure. On 03/29/2025 at 8:36 PM, it was noted R1 was having difficulty swallowing and family was notified and asked if they wanted R1 to be transferred to the hospital for evaluation. The family denied the request. On 03/29/2025 at 10:32 PM, it was noted R1 was having difficulty swallowing liquids. R1 was able to take 3 sips of liquids. On 03/30/2025 at 3:09 PM, it was noted R1 was having difficulty swallowing. On 03/30/2025 at 9:59 PM it was noted difficulty swallowing continues.
During interviews with Staff S1-S8, were asked how you ensure residents stay hydrated, eight (8) out of eight (8) stated fluids are always available in the bistro area and staff offer, remind, and encourage residents to drink water and other fluids. Additionally, Staff S1-S8 were asked if R1 was consuming fluids after their return from the hospital, eight (8) out of eight (8) stated R1 was consuming minimal fluids, was having difficulty swallowing, and in some instances the fluid would come back out.
During interviews with Residents R2-R7, were asked if there are fluids available at all times, seven (7) out of seven (7) stated there is always water, juice, and coffee available and staff are always asking if they would like something to drink.
During interviews with Witnesses W1-W3, were asked if their resident is getting plenty of fluids to stay hydrated, two (2) out of three (3) stated yes the resident is getting plenty of fluids and they are always offered.

Allegation: Due to staff neglect, resident had malnutrition.


The allegation alleges resident was exhibiting signs of malnutrition, and resident has not eaten or has eaten very little.
During record review, LPA received and reviewed Resident R1’s Progress notes. On 03/29/2025 at 1:09 PM, it was noted that R1 refused breakfast but drank 50% of an ensure. At lunch R1 was transferred to the dining room but did not consume lunch. On 03/29/2025 at 8:36 PM, it was noted R1 was having difficulty swallowing and family was notified and asked if they wanted R1 to be transferred to the hospital for evaluation, the family declined. On 03/29/2025 at 10:32 PM, it was noted R1 was unable to consume dinner and was having difficulty swallowing liquids. R1 was able to take 3 sips of thickened liquids and swallowed
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20250401153101
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: 04/10/2025
NARRATIVE
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with guidance and encouragement. On 03/30/2025 at 3:09 PM, it was noted R1 was having difficulty swallowing and needs encouragement. On 03/30/2025 at 9:59 PM it was noted difficulty swallowing continues.
During the facility inspection, LPA observed snacks and fruits available in the bistro area on both the first and second floor. Additionally, LPA observed caregivers and other staff offering snacks to residents throughout the facility.
During interviews with Staff S1-S9, were asked how they ensure residents receive enough nutrients to prevent malnourishment, nine (9) out of nine (9) stated residents are provided three (3) meals a day and snacks are always available and offered to residents throughout the day. Nine (9) out of nine (9), additionally stated that if a resident does not want to eat their meals their doctor is contacted and often will order Ensure and Boost and/or approve a Silverado Milk Shake or Magic Cup to ensure they get their nutrients. Additionally, S1 and S9 stated the menu is developed by a dietitian to ensure they are well balanced. During interviews with Staff S1-S8, were asked if R1 was eating when they returned from the hospital, eight (8) out of eight (8) stated R1 was refusing most meals and snack, and that times R1 did take a bite R1 was having difficulty swallowing and would pocket the food in their mouth.
During interviews with Residents R2-R7, were asked if they are provided with meals and snacks throughout the day, six (6) out of six (6) stated they receive three (3) meals a day and snacks anytime.
During interviews with Witnesses W1-W3, were asked if their resident is provided with three (3) balanced meals and snacks throughout the day, two (2) out of three (3) stated residents are provided meals and snacks throughout the day and have no concerns of malnourishment.

Allegation: Staff are not following resident’s special diet.


The allegation alleges the facility is not following the special diet orders for a resident.
During the facility inspection, LPA observed a binder in the kitchen that has residents Diet request Forms. LPA observed Staff S9 preparing trays for dinner and observed residents who have Dietary Orders have a card placed on their tray with their orders.
During record review, LPA received and reviewed all residents Dietary Orders. Additionally, LPA received and reviewed the facility Menu created by a dietitian from Dining Manager by Dining RD. The Dining RD Meal Service Observation and Procedures form dated 03/05/2025, was reviewed by LPA, that indicated for the Menu it meets the standards and spreadsheets have all the diets for POS diets. Furthermore, the Menu Sub Log meets the standards for evidence of nutritionally equivalent substitutions.
During interviews with Staff S1-S9, were asked how residents Dietary Orders are met and tracked, nine (9)
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20250401153101
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: 04/10/2025
NARRATIVE
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out of nine (9) stated the nurse receives the orders, fills out a Diet Request Form and signs and copies it, then takes the copies to the chef who signs one and puts the other in the binder, and when meals are served there is a card on the tray that has the residents name and orders.
During interviews with Residents R2-R7, were asked if the food and snacks they receive meet their Special Dietary Orders, six (6) out of six (6) stated their dietary orders are followed.
During interviews with Witnesses W1-W3, were asked if their residents dietary orders are met, two (2) out of three (3) stated yes their resident's dietary orders are met.

Allegation: Due to lack of supervision, resident has had multiple falls.


The allegation alleges resident has fallen multiple times at the facility resulting in hospitalization.
During the facility inspection, LPA observed all walkways in the facility clear of hazards and obstructions. LPA observed some residents had fall mats next to their beds and their beds lowered close to the ground.
During record review, LPA received and reviewed Resident R1’s Comprehensive Assessment dated 05/29/2024, that indicates R1 does not have a history of falls and has a low risk of fall. It was noted that R1 slid out of bed over six (6) months ago. LPA received and reviewed R1’s Service Plan Detail dated 06/28/2024, that stated the Goal for Fall is to “maintain and /or maximize safety with mobility/transfer; will minimize injury related to falls.” The Action states “interventions in place to minimize fall risk and decrease risk of injury. Monitoring Devices: Tabs alarm, pressure alarm.” And “Monitor and assist as needed for safety.” Additionally, LPA received and reviewed a Service Plan Detail for R1 date 12/05/2024, that states the same Goal for falls with added Action of Physical Therapy and Occupational Therapy, and the use of fall mats. LPA received and reviewed Special Incident Reports (SIR) for R1 dated 11/22/2024, 09/20/2024, and 08/31/2024 for incidents where R1 was found on the floor in their room. On the days two (2) of the falls occurred, R1 was admitted to the hospital for additional monitoring not related to the fall.
During interviews with Staff S1-S8, were asked how they minimize falls of residents, eight (8) out of eight (8) stated staff do frequent checks on residents in their rooms, supervise those in the common areas, ensure walkways are always clear, and if they are a fall risk we have tag alarms, fall mats, and high/low beds. Additionally, Staff S1-S8 were asked if R1 was a fall risk, eight (8) out of eight (8) stated yes R1 was a fall risk, and checks were conducted every 2-hours.
During interviews with Residents R2-R7, were asked if they had any falls at the facility due to lack of supervision, six (6) out of six (6) stated they have not experienced any falls due to lack of supervision. Two (2) out of six (6) stated they experienced falls due to tripping and fell when they were not here.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20250401153101
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: 04/10/2025
NARRATIVE
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During interviews with Witnesses W1-W3, were asked if their resident had sustained falls due to lack of supervision, two (2) out of two (2) stated stated their resident has not sustained any falls due to lack of supervision.

During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

LPA did not observe or cite any deficiencies.

An exit interview was conducted with Administrator, Taylor Giunto, and a copy of this report was provided.

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

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6