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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603266
Report Date: 07/01/2025
Date Signed: 07/01/2025 07:54:10 PM

Document Has Been Signed on 07/01/2025 07:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:SILVERADO SENIOR LIVING-BEVERLY PLACEFACILITY NUMBER:
198603266
ADMINISTRATOR/
DIRECTOR:		GIUNTO,TAYLOR L.FACILITY TYPE:
740
ADDRESS:330 N. HAYWORTH AVETELEPHONE:
(323) 852-9200
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY: 256CENSUS: 110DATE:
07/01/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:06 PM
MET WITH:Stephanie Brynjolfson TIME VISIT/
INSPECTION COMPLETED:
04:07 PM
NARRATIVE
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On July 1, 2025, Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced case management visit. LPA met with Executive Director Stephanie Brynjolfson, and explained the purpose of the visit is in reference to an incident that occurred with Resident #1 (R1) on June 18, 2025.

The Department received an Unusual Incident Report LIC 624 on June 25, 2025, regarding an incident that occurred at 7:45 PM. It was reported that Resident #1 (R1) was able to elope from the community unsupervised. (R1) had been admitted to the community on June 17, 2025, and was diagnosed with a Major Neurocognitive Disorder (NCD). (R1) resided on the third floor, known as "the Loft." According to Staff #1 (S1), (R1) had one-on-one private care staff who had taken a break. During this time, S1 informed the Silverado care staff assisting another resident. In a matter of seconds, while the care staff were distracted, (R1) left without supervision. (R1) managed to operate the elevator and descend to the first-floor lobby, passing the front desk receptionist without being recognized, and exited through the front doors. (R1) was found unattended on Fairfax Avenue. (S1) stated that once returned to the community, (R1) had a whole body and skin assessment, saw no signs of injuries or discomfort. (S1) notified the family representative and medical physician of the incident.

The Department reviewed (R1)'s Medical Assessment (dated April 17, 2025) and Physician's Order Review. It revealed that (R1) has a history of disorientation and sundowning behavior, which can be associated with wandering and eloping behaviors in residents diagnosed with (NCD).

The licensee violates Title 22, Section 87411, Personnel Requirements. California Code of Regulations (Title 22, Division 6, Chapter 8), deficiencies were observed, and citations were issued (ref. LIC 809-D).
An exit interview was conducted, and a copy of the Evaluation Report and Appeal Rights was provided to Stephanie Brynjolfson.
NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/01/2025 07:54 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 07/01/2025 at 03:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SILVERADO SENIOR LIVING-BEVERLY PLACE
FACILITY NUMBER: 198603266

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/15/2025
Section Cited
CCR
87411(a)

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87411 Personnel Requirements - General (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required...
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The Licensee will adhere to the regulations and ensure review of Title 22, Section 87411. The Licensee will provide care staff training to address (NCD) wandering and elopement behaviors—proof of correction, including a sign sheet, to be sent by fax to the El Segundo Regional office at 424-544-1016 by 07/15/25.
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This requirement is not met as evidence by:
Based on interview, Licensee failed provide necessary supervision services to meet resident needs and eloped from the facilty unatttended. This violation possesses a potential Health and Safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Ernand Dabuet
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2025


LIC809 (FAS) - (06/04)
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