198603266-10-9-2025-11-AS-SCIS-DMJU7Q-20251017152018

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603266
Report Date: 10/09/2025
Date Signed: 10/09/2025 03:30:04 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/02/2024 and conducted by Evaluator Elvira Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20241202213733

FACILITY NAME:	SILVERADO SENIOR LIVING-BEVERLY PLACE		FACILITY NUMBER:	198603266
ADMINISTRATOR:	GIUNTO,TAYLOR L.		FACILITY TYPE:	740
ADDRESS:	330 N. HAYWORTH AVE		TELEPHONE:	(323) 852-9200
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90048
CAPACITY:	256	CENSUS: 114	DATE:	10/09/2025
		UNANNOUNCED	TIME BEGAN:	08:12 AM
MET WITH:	Stephanie Brynjolfson		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Resident sustained falls resulting in multiple injuries due to staff neglect.
Staff did not meet resident's hygiene needs.

INVESTIGATION FINDINGS:

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On 10/09/2025, the department conducted a subsequent complaint visit to this facility to conclude the investigation and deliver findings on the above-named allegations. The department met Stephanie Brynjolfson, Administrator, and explained the purpose of the visit. The department was granted access to the facility.

The investigation consisted of the following: On 12/04/24, the department requested the following documents: staff roster and resident roster. The department reviewed resident #1 (R1) file, and collected copies of Physician's Report, Identification and Emergency Information, Resident Appraisal, Service Plan (dated: 12/4/2024), and Progress Notes, (dated 11/17/2024-12/01/2024). Additionally, the department conducted a health and safety check and a tour of the entire facility. On 12/09/24, the department conducted an interview with witness #1 (W1).

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20241202213733

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 PLACE	FACILITY NUMBER: 198603266
	VISIT DATE: 10/09/2025

NARRATIVE

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On 12/12/24, the department conducted an interview with staff #1 (S1). On 12/13/24, the department conducted interviews with W1, and staff #1-#4 (S1-S4), and attempted to interview residents #2-#3 (R2-R3). On 01/21/2025, the department obtained medical records from Cedar Sinai Medical Center, and on 02/26/25, the department obtained medical records from Victory Hospice for R1. Furthermore, on 02/26/25, the department conducted an interview with staff #5 (S5). On 10/09/25, the department received the following documents: staff roster, resident roster, and Shower Logs for the months of November-December 2024. The department conducted interviews with S3-S4, and residents #4-#12 (R4-R12). Lastly, the department conducted a tour of the facility.

The investigation revealed the following:
Allegation: Resident sustained falls resulting in multiple injuries due to staff neglect. It is being alleged that a resident sustained two un-witnessed falls while in care, resulting in a fractured wrist, three fractured ribs, and a laceration on forehead due to neglect. The department conducted a review of records. Per Identification and Emergency Information form resident 1 (R1) was admitted to the facility on 08/12/2022 and was initially assessed as ambulatory with the use of a walker.

Medical Records from Victory Hospice show that hospice services were initiated for R1 on 10/29/2024. Victory Hospice conducted an assessment of R1, and notes from that assessment state that R1’s health was declining, and that R1 was no longer ambulatory and considered a fall risk. On 11/12/2024, R1 was seen by Registered Nurse #1 (RN1) of Victory Hospice. RN1 stated that a head-to-toe assessment was completed of R1, and that there were no signs of pain.

Facility Progress Notes for R1 revealed that on 11/17/24, R1 had an un-witnessed fall and was found on the floor of their room. It was noted that R1 denied hitting their head. An assessment was conducted by facility staff and there were no visible marks noted. R1 was able to move all extremities but complained of back pain and was given Tylenol for pain.

The department reviewed visit notes from Victory Hospice. Per the notes R1 was seen by hospice Licensed Vocational Nurse #1 (LVN1) on 11/18/2024 for a follow up after a fall which occurred on 11/17/2024. A physical assessment completed during visit showed a contusion on R1’s lower back. Hospice records noted that there were no other wounds observed and R1 appeared in fair health.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20241202213733

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 PLACE	FACILITY NUMBER: 198603266
	VISIT DATE: 10/09/2025

NARRATIVE

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Per visit notes from Victory Hospice, on 11/25/2024, R1 was seen by Hospice LVN1. A physical assessment completed during visit showed a contusion on R1’s lower back. Hospice records noted that there were no other wounds observed and R1 appeared in fair health.

Per visit notes from Victory Hospice, on 11/26/2024, R1 was seen by RN1, and a head-to-toe assessment was completed of R1. It was noted that R1 displayed signs of depression and forgetfulness, and that there were no signs of pain.

The department reviewed Facility Progress Notes which show that on 11/26/2024 R1 was observed with swelling of left wrist. Facility staff contacted Victory Hospice.

Further review of visit notes from Victory Hospice dated 11/29/2024, state that R1 was seen by Licensed Vocational Nurse #2 (LVN2) who stated that a physical assessment showed R1 had pain in their left wrist and lower abdomen below the rib cage. R1 flinched when those areas were touched and left wrist displayed redness and swelling.

The department reviewed Facility Progress Notes which noted that on 12/01/24 R1 had an un-witnessed fall and was found on the floor of their room. R1 was found lying on the left side of the bed with their head against the corner nightstand. R1 sustained an abrasion on the top left of their forehead, a bruise on their forehead, a red spot under their left eye, a bruise on their left shoulder and a bruise to their left hip. Victory Hospice and responsible party were notified, and R1 was taken via ambulance at 12:30 PM. An Unusual Incident/Injury Report was submitted to the department on 12/05/2024, depicting the same incident and adding that R1 was found around 08:45 AM and was transferred to Cedar Sinai Emergency room for further evaluation after a discussion with residents family.

The department reviewed medical records from Cedar Sinai Medical Center, which showed that R1 was admitted on 12/01/2024 and was diagnosed with fractures of the posterior medial left ninth through twelfth ribs with a small left pleural effusion, a nondisplaced fracture of the left wrist, and a four cm left forehead laceration.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 11-AS-20241202213733

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 PLACE	FACILITY NUMBER: 198603266
	VISIT DATE: 10/09/2025

NARRATIVE

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The department conducted interviews with S1-S5. Of those interviewed, 5 out of 5 staff could not corroborate the allegation. 4 out of 5 staff stated that R1 was moved to the second floor for a higher level of care and supervision. 3 out of 5 staff stated that after the second fall, R1 was provided with a bed that was six inches from the ground with high-low capabilities. An interview with S2 revealed that R1 had their first fall on 11/17/2024 and was found on the floor near their bed. S5 conducted a full body assessment and determined that R1 was able to move all their extremities without concern. After R1’s first fall, facility moved them to the second floor for a higher level of care as second floor of the facility has fall mats, two person assists, and more rotations completed by staff on the residents. S2 stated that R1’s second fall occurred on 12/01/2024 and that S4 found R1 on the floor lying on their left side with their head against the corner of their nightstand. S4 reported to S2 that R1 sustained an abrasion to their top left forehead, and there was a red spot under their left eye. R1 also sustained a contusion on their left shoulder and left hip. Once notified, S2 called Victory Hospice at 0845 hours and left a voicemail. S2 called Victory Hospice again at 0907 hours and reported the incident to Ana at Victory Hospice. S2 then called R1’s Power of Attorney (POA) to inform them of the incident, then called 911 and R1 was transported via ambulance to Cedar Sinai Hospital.

The department attempted to interview R2-R3 but was unable to due to cognitive impairment. The department was unable to interview R1, as the resident passed away.

An interview conducted with W1 revealed that R1 was at the facility from 08/15/2022 until 12/09/2024. W1 stated that R1 had their first fall on 11/17/2024, and that the facility informed them that that R1 was okay. After the first fall, R1 was moved to the second floor of the facility on 11/25/202 because R1 required a higher level of care. W1 stated that R1 sustained their second fall on 12/01/2024 and during fall R1 hit their head on the nightstand and sustained an abrasion to their forehead. R1 was taken to Cedar Sinai Hospital where they received stitches on their head, and were diagnosed with a left fractured wrist, and three fractured ribs. W1 stated that R1’s bed was changed to a high low bed as it was lower to the ground and that the facility held a conference with them to discuss options for improving R1’s care.

Based on interviews conducted, and records reviewed, the department did not find sufficient evidence to support allegation. 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.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 11-AS-20241202213733

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 PLACE	FACILITY NUMBER: 198603266
	VISIT DATE: 10/09/2025

NARRATIVE

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Allegation: Staff did not meet resident's hygiene needs. It is being alleged that a resident was observed with blood in their hair and had not been bathed. On 10/09/25, the department conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. 4 out of 4staff said residents receive two showers a week and as needed. An interview with S1 revealed that R1 was showered twice a week, and as needed. S2 stated that Victory Hospice staff was assisting R1 with showers during the months of November 2024-December 2024.

On 10/09/25, the department conducted interviews with R4 – R12. Of those interviewed, 4 out of out of 9 residents said that staff are meeting their hygiene and grooming needs, 2 out of 9 residents said they did not know if staff are meeting their hygiene and grooming needs, and 3 out of 9 residents did not answer. 4 out of 9 residents said that staff does assist them with bathing, 3 out of 9 residents said they did not know if staff assists them with bathing, and 2 out of 9 residents did not answer. 6 out of 9 residents said staff has not denied them services, and 3 out of 9 residents did not answer.

A review of R1’s Physician’s Report documented under “Capacity for Self-Care” that the resident requires assistance with bathing. A review of the facility’s Shower Logs for the dates of November-December 2024 documented that residents were scheduled for at least two showers a week. The Shower Log for November 2024 documented that R1 received showers from staff at Victory Hospice. There were no showers for the month of December 2024 documented in the Shower Log.

On 10/09/25, the department conducted a tour of the facility and observed residents to be clean and free from any odors.

Based on interviews conducted, and records reviewed, the department did not find sufficient evidence to support allegation. 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 Stephanie Brynjolfson, and a copy of the report was provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025

LIC9099 (FAS) - (06/04)

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