198320514-2-5-2026-11-AS-EMAZ-DRF48V-20260218175321

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320514
Report Date: 02/05/2026
Date Signed: 02/05/2026 04:49:18 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
01/02/2026 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20260102134450

FACILITY NAME:	SILVERADO ROLLING HILLS		FACILITY NUMBER:	198320514
ADMINISTRATOR:	GIUNTO, TAYLOR		FACILITY TYPE:	740
ADDRESS:	2455 PACIFIC COAST HWY		TELEPHONE:	(949) 240-7200
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	68	CENSUS:	DATE:	02/05/2026
		UNANNOUNCED	TIME BEGAN:	01:02 PM
MET WITH:	Christina Hale		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Facility staff does not ensure resident is provided adequate supervision resulting in resident having multiple falls while in care.

INVESTIGATION FINDINGS:

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On 02/05/2026, Licensing Program Analyst, Wendy Gibbs, conducted a subsequent unannounced Complaint Visit to the facility listed above. LPA met with Administrator, Christina Hale, and the purpose of today’s visit was explained. LPA was granted entry into the facility.
The investigation consisted of the following:
During the initial visit conducted on 01/08/2026, LPA inspected the facility, interviewed Staff S1, S2, S4-S6, interviewed residents Responsible Party W1 and W2, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Physician’s Report, Needs and Service Plan, Fall Assessment, Admission Agreement, Fall Plan, Hospice Plan, incident reports, and Charting Notes.
During a subsequent visit conducted on 01/23/2026, LPA inspected the facility, interviewed Residents R2-R6, and interviewed resident’s Responsible Party W3-W5.
During today’s visit, LPA interviewed Staff S3, S7 and S8, received training logs for Staff S3-S8, and in-service logs.
The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026

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 3

Control Number 11-AS-20260102134450

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: 198320514
	VISIT DATE: 02/05/2026

NARRATIVE

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Allegation: Facility staff does not ensure resident is provided adequate supervision resulting in multiple falls while in care.
The allegation alleges a resident experienced three (3) falls from their bed during the month of December 2025.

During the facility inspection, LPA observed staff escorting residents to meals, activities, and the restrooms. LPA observed some residents have hip protectors on. LPA observed in rooms 101, 225, and 116, the beds are on the lowest setting and there are fall mats to the side of the beds.

During record review, LPA received and reviewed the Staff Schedule that indicates there are two (2) caregivers and a nurse working the NOC shift. LPA received and reviewed Staff S3-S8 training logs that indicate they have received the following training on Relias within the last year, Silverado Fall Management for Residents with Dementia, Slip, Trip, and Fall Prevention, and Minimizing Slips, Trips, and Falls. LPA received and reviewed in-service logs that indicate staff received training regarding Hip Saver, Fall/Injury Management, Prevention, and Precautions.
LPA received and reviewed Incident Forms dated 12/02/2025 and 12/21/2025, that indicated Resident R1 was observed on the floor. The reports state there were “no signs of injury” and R1 was “unable to verbalize what occurred.” One report stated R1 was assisted back to bed and “magnet bed alarm was placed.” Additionally, LPA received and reviewed R1’s Nursing Admission Evaluation Results and Service Plan, dated 11/10/2025, that indicates R1 has a history of falls, but not within three (3) months of the assessment. LPA observed R1 uses ambulatory aids such as a walker or cane, and “may require hands on assistance by staff” when ambulating and transferring, and “cues for safety.” In R1’s Charting Notes, LPA observed S2 and W1 met on 12/23/2025 to discuss implementation of a second alarm in addition to the tag alarm.
During interviews with Staff S1-S8, were asked if they feel there is enough staff on each shift to provide adequate supervision to prevent or minimize falls, seven (7) out of eight (8) stated yes, they feel there is enough staff to provide adequate supervision to minimize falls.
During interviews with Residents R2-R6, they were asked if they feel there is enough staff to provide adequate supervision to prevent or minimize falls, five (5) out of five (5) stated yes, they believe there is enough staff to provide adequate supervision. Additionally, Residents R2-R6 were asked if the facility take precautions to minimize falls, four (4) out of five (5) stated yes, the facility takes precautions to minimize or prevent falls. One (1) resident stated they do not have any concerns regarding falls.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20260102134450

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: 198320514
	VISIT DATE: 02/05/2026

NARRATIVE

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During interviews with Resident’s Responsible Parties W1-W6, they were asked if staff provide adequate supervision to prevent or minimize falls, five (5) out of six (6) stated yes, they believe there is enough staff to provide adequate supervision to prevent or minimize falls. Additionally, six (6) out of six (6) stated the facility takes precautions to minimize or prevent falls.

During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) 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(s) is/are unsubstantiated.

LPA did not observe or cite any deficiencies during today’s visit.

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

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026

LIC9099 (FAS) - (06/04)

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