198603266-1-31-2024-11-AS-SCIS-D333BV-20240304170659

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603266
Report Date: 09/29/2023
Date Signed: 01/31/2024 11:10:08 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
08/28/2023 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20230828144351

FACILITY NAME:	SILVERADO SENIOR LIVING-BEVERLY PLACE		FACILITY NUMBER:	198603266
ADMINISTRATOR:	ALMA VIDA A GWINN		FACILITY TYPE:	740
ADDRESS:	330 N. HAYWORTH AVE		TELEPHONE:	(323) 852-9200
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90048
CAPACITY:	256	CENSUS:	DATE:	09/29/2023
		UNANNOUNCED	TIME BEGAN:	09:56 AM
MET WITH:	Jean		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not intervene in resident-on-resident altercations.
Staff did not ensure that resident received medical attention while in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

This report serves as an amendment to clarify findings. It supersedes the complaint investigation findings reflected on report created 9/29/2023.

On 9/29/23, Licensing Program Analyst, Felisa Shirley, returned to above name facility to conclude investigation into said allegations. LPA Shirley met with Jean Deguzman, Director of Health Services, and explained the purpose of today's visit and was granted access.

On 9/6/23 LPA requested and obtained copies of the following documents: Staff and Resident Rosters, resident files which contained, Preplacement Appraisals, Physician’s Reports, Resident Identification and Emergency Information, Needs and Services Plans, and LIC 624’s for the month of July 2023. On 9/6/23 LPA conducted interviews with Taylor Ginuto, Administration Specialist, (S-1) staff 2 – Staff 10 (S2 – S10), resident 1 – resident 10 (R1 - R10), and witness (W1).

Cont'd on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

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 4

Control Number 11-AS-20230828144351

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SILVERADO SENIOR LIVING-BEVERLY PLACE	FACILITY NUMBER: 198603266
	VISIT DATE: 09/29/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

This report serves as an amendment to clarify findings. It supersedes the complaint investigation findings reflected on report created 9/29/2023.
The investigation revealed the following:

Allegation: Staff did not intervene in resident-on-resident altercations.
It is alleged that a resident was walking to lunch and another resident hit them in the head. LPA interviewed staff S1– S10, and 10 out of 10 stated that no resident had reported that they were physically attacked by another resident. LPA interviewed residents R1 – R10, and 9 out of 10 stated that they had never been attacked by another resident.

Based on interviews there is insufficient evidence to support the allegation: "Staff did not intervene in resident-on-resident altercations." 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.

Allegation: Staff did not ensure that resident received medical attention while in care
It is alleged that a resident was shoved by another resident and their shoulder was injured to the point of needing an injection for pain. LPA interviewed staff S1 – S10, and 9 out of 10 of those interviewed stated that no residents reported that they were physically attacked by other residents. S1 added that at least one resident reported to them that they were attacked by a homeless male while out walking with a friend. LPA interviewed R1 – R10, and 9 out of 10 residents denied that anyone has hit or attacked them there. R1 stated that they told S5 and S1 that they were physically attacked. S1 called the police regarding the incident but no official report was taken and no injury was noted per S1. S1 also added that no LIC 624 form was completed and submitted to Licensing at the time. During LPA's interview with S10, LPA interviewed S10 who stated that R1 complained of chest and shoulder pain. R1 was evaluated by facility nurse and R1 was referred to Valley Internal Medicine where the resident was evaluated. LPA interviewed W1 regarding alleged altercation and both R1 and W1 stories coincided with each others account of what happened.

Cont'd on 9099-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 11-AS-20230828144351

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SILVERADO SENIOR LIVING-BEVERLY PLACE	FACILITY NUMBER: 198603266
	VISIT DATE: 09/29/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

This report serves as an amendment to clarify findings. It supersedes the complaint investigation findings reflected on report created 9/29/2023.

Based on interviews there is insufficient evidence to support the allegation: "Staff did not intervene in resident-on-resident altercations." 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.

An exit interview was conducted with Administrator Assistant, Stephanie Brynjolfson and a copy of the report was provided.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20230828144351

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SILVERADO SENIOR LIVING-BEVERLY PLACE	FACILITY NUMBER: 198603266
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES	PLAN OF CORRECTIONS(POCs)
Type B HSC	1 2 3 4 5 6 7	1 2 3 4 5 6 7
	1 2 3 4 5 6 7	1 2 3 4 5 6 7
	1 2 3 4 5 6 7	1 2 3 4 5 6 7
	1 2 3 4 5 6 7	1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4