198320514-4-7-2026-11-AS-EMAZ-DTSTAC-20260505143320

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320514
Report Date: 04/07/2026
Date Signed: 04/07/2026 06:00:10 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
03/10/2026 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20260310113943

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: 43	DATE:	04/07/2026
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Christina Hale		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff worked while under the influence of drugs, impairing their ability to provide adequate care and supervision, which presents a risk to residents in care
Staff did not maintain facility free from hazards, resulting in a resident sustaining an injury
Staff spoke inappropriately to resident
Staff handled resident in a rough manner
Staff did not properly report incident(s)

INVESTIGATION FINDINGS:

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On 04/07/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an 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 today’s visit, LPA inspected the facility, interviewed Staff S1-S6, interviewed Residents R1-R6, and interviewed resident Responsible Party’s W1-W3.
During the initial visit conducted on 03/19/2026, LPA inspected the facility with the Director of Plant Operations (S3), interviewed Staff S1-S3, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Unusual Incident/Injury Reports (dated 02/19/2026, 02/09/2026, and 02/06/2026), resident R1’s Progress Notes (dated 01/10/2026 to 03/19/2026), Resident Incident Log (dated 01/01/2026 to 03/19/2026), Maintenance Report Log (dated 04/08/2025 to 03/18/2026), Maintenance Incident Statement (dated 03/11/2026 and 03/12/2026),

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026

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 5

Control Number 11-AS-20260310113943

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: 04/07/2026

NARRATIVE

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staff Alcohol and Substance Abuse Policy in the employee handbook, Associate Acknowledgement of policy (dated 04/30/2025, 02/23/2013, and 03/14/2025), and Torrance Police Department Case Information (dated 03/03/2026 and 03/13/2026).
The investigation revealed the following:
Allegation: Staff worked while under the influence of drugs, impairing their ability to provide adequate care and supervision, which presents a risk to residents in care.
The allegation alleges that staff are working while impaired, narcotics have fallen out of a staff’s pocket, and staff were observed getting high during a break.

During record review, LPA received and reviewed the Alcohol and Substance Abuse Policy on page 40 of the Employee Handbook signed and dated by staff when they are hired. It states “the purpose of this policy is to inform every associate that Silverado does not condone or tolerate alcohol or drug use in the workplace.

During interviews with Staff S1-S6, were asked if they have worked while under the influence, six (6) out of six (6) stated they have not worked while under the influence. Additionally, Staff S1-S6 were asked if they have observed staff working while under the influence, six (6) out of six (6) stated no, they have not observed staff working while under the influence.
During interviews with Resident R1-R6, were asked if they have observed staff working while under the influence, five (5) out of six (6) stated they have not seen staff working while under the influence. One resident did not answer.
During interviews with resident responsible party W1 -W3, were asked if they have observed staff working while under the influence of a mind altering substance, three (3) out of three (3) stated no, they have not observed staff working while under the influence.

Allegation: Staff did not maintain facility free from hazards, resulting in a resident sustaining an injury.

The allegation alleges that multiple exit doors are nonfunctional and a resident fell after tripping on a wet floor sign and fan.

During the facility inspection, LPA tested all exit doors and observed the egress system and doors function properly and open as required. LPA observed the access hatches to the roof were closed and properly secured. Additionally, LPA was informed the carpets were just cleaned and LPA observed signs for “Wet Floors,” and fans against the walls in the hallways, not blocking the walkway.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 11-AS-20260310113943

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: 04/07/2026

NARRATIVE

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LPA observed all walkways and hallways were clean, clear, and free of hazards, debris, and obstructions.
LPA received and reviewed Maintenance Logs that indicates what was reported that need fixed, and when and who repaired it.
During interviews with Staff S1-S6, were asked how they ensure the facility is kept free from hazards, six (6) out of six (6) stated rounds are done multiple times a day by the maintenance director, and the directors to ensure there are no hazards. Additionally, Staff S1-S6, were asked if there have been any issues with the exit doors, six (6) out of six (6) stated there have been no issues with the egressed exit doors.
During interviews with Residents R1-R6, were asked how the staff ensure the facility is free from hazards, five (5) out of six (6) stated the staff make sure walkways are clear, they pick up papers on the floor, and the staff will walk with the residents to make sure they get there safe. Additionally, Residents R1-R6, were asked if there have been any issues with the exit doors or the exit doors being left open, five (5) out of six (6) no, there have been no issues with the doors. One resident did not answer.
During interviews with resident responsible party W1 -W3, were asked if staff ensure the facility is free from hazards, three (3) out of three (3) stated they have not observed any hazards at the facility.

Allegation: Staff spoke inappropriately to a resident

The allegation alleges staff spoke inappropriately to a resident, calling them an idiot and cussing at them.

During the facility visit, LPA observed staff’s interactions with residents during meals, providing assistance, and activities. LPA observed the staff speaking respectfully to residents.

During record review, LPA received and reviewed staff’s signed and dated Statement Acknowledging Requirements to Report Suspected Abuse of Dependent Adults and Elders. LPA received and reviewed staff’s Relias Transcript that include training regarding Resident Rights, Mandated Reporting-Elder and Dependent Abuse and Neglect in CA, and Silverado Communicated with Resident Living with Dementia. Additionally, LPA received and reviewed staff’s General Standard of Conduct on page 14 of the employee handbook that states the following infractions may result in disciplinary action, up to and including immediate termination of employment: “insubordination or other malicious or threatening conduct;” and “intentional or negligent violation of safety or health standard.”
During interviews with Staff S1-S6, were asked if they have spoken to a resident in an inappropriate manner or have heard a staff speaking to a resident in an inappropriate manner, six (6) out of six (6) stated no, they have not spoken to a resident inappropriately or heard staff speak inappropriately to a resident.
During interviews with Residents R1-R6, were asked if staff have spoken to them or another resident inappropriately, five (5) out of six (6) stated no. One (1) resident did not answer.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 11-AS-20260310113943

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: 04/07/2026

NARRATIVE

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During interviews with resident’s Responsible Party W1-W3, were asked if they heard staff speaking inappropriately to any resident, three (3) out of three (3) stated no.

Allegation: Staff handled resident in a rough manner

The allegation alleges that while assisting a resident up from a fall the staff handled them in a rough manner.

During the facility visit, LPA observed staff assisting residents with transferring from the wheelchair to their bed. LPA observed staff using appropriate hand placement while assisting with transferring a resident.

During record review, LPA received and reviewed staffs signed and dated Statement Acknowledging Requirements to Report Suspected Abuse of Dependent Adults and Elders. Additionally, LPA received and reviewed staff’s General Standard of Conduct on page 14 of the employee handbook that states the following infractions may result in disciplinary action, up to and including immediate termination of employment: “insubordination or other malicious or threatening conduct;” and “intentional or negligent violation of safety or health standard.” LPA received and reviewed staff’s Relias Transcript that include training regarding Resident Rights, Mandated Reporting-Elder and Dependent Abuse and Neglect in CA, and Silverado Communicated with Resident Living with Dementia.
During interviews with Staff S1-S6, were asked if they have or have observed staff handle a resident in a rough manner, six (6) out of six (6) stated no, they have not.
During interviews with Residents R1-R6, were asked if staff have handled them in a rough manner, five (5) out of six (6) stated no, they have not been handled in a rough manner.
During interviews with resident’s Responsible Party W1-W3, were asked if they have observed staff handle a resident in a rough manner, three (3) out of three (3) stated no they have not.

Allegation: Staff did not properly report incidents

The allegation alleges that incident reporting was not done regarding the residents fall.

LPA received and reviewed Resident Incident Log from 01/01/2026 to 03/31/2026, that indicates R1 was observed on the floor on 02/12/2026. Additionally, LPA received and reviewed Resident R1’s Progress Notes from 01/01/2026 to 03/31/2026 that indicates on 02/12/2026 R1 was observed on the floor, was assessed by LVN, assisted to a standing position, and R1 ambulated to their room without assistance. LPA observed R1’s Responsible Party was notified and R1 was on Alert Charting and had additional monitoring till 02/15/2026. Additionally, LPA received and reviewed Unusual Incident/Injury Report’s submitted to Community Care Licensing (CCL) for the month of February. The incident reports are regarding residents who were observed on the floor and were transferred to the Emergency Room for additional assessment.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 11-AS-20260310113943

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: 04/07/2026

NARRATIVE

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During interviews with Staff S1-S6, were asked if all incidents are reported to CCL, six (6) out of six (6) stated all incidents that require first aid, a transfer to the hospital, refusal of transfer to the hospital, or incidents that interrupts daily operation is reported to licensing.
During interviews with Residents R1-R6 were asked if to their knowledge are incidents reported to CCL, five (5) out of six (6) stated yes, they are. One (1) resident did not answer.

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 site any deficiencies.

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

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026

LIC9099 (FAS) - (06/04)

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