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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603266
Report Date: 09/25/2024
Date Signed: 09/25/2024 12:38:13 PM


Document Has Been Signed on 09/25/2024 12:38 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:GIUNTO,TAYLOR L.FACILITY TYPE:
740
ADDRESS:330 N. HAYWORTH AVETELEPHONE:
(323) 852-9200
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY:256CENSUS: 111DATE:
09/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Stephanie Brynjolfson, AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Sparkle Day conducted a Case Management site visit to the facility to ascertain information pertaining to the Licensee-initiated Incident Report which occurred on 09/06/2024. LPA met with Staff #1 Administrator Stephanie Brynjolfson who assisted with the visit.

On 9/6/24 at 8:15am resident #1 (R#1) received incorrect dosage of Ativan from Silverado Hospice RN, W#1 Jane Edwards. R#1 was expected to take a dosage of .025 of Ativan and was administered a dosage of 2.5 mg of Ativan. Immediately after administering incorrect dosage of Ativan to R#1, the Hospice Nurse informed the Nurse at the Nurse station Staff #2 Maria Gabriel who informed the Asst Director of Health Services , The Health Services Director, the Physician and the family. During todays visit LPA interviewed Administrator Stephanie Brynjolfson Staff #1, Director of Health Services Staff #3, Tommy Anderson and Asst Director of Health Services Staff #4 , Maria Roldan], Facility staff then followed Physician instructions Assessed and monitored R#1.
LPA reviewed the following current staff training : Identifying and Managing Medication Errors and Adverse Consequences dated 9/20/24 ,Administering Medications to Hospice Residents instead of Hospice nurses dated 9/9/2024 and Resident Medication distribution dated 9/20/24
LPA observed a new policy of the facility regarding Medication distribution with Hospice nurses indicating whenever a resident is on hospice and needs medication the hospice nurse will communicate the information to the Silverado Beverly Place charge nurse. At that time the charge nurse will verify all orders and administer the medication to the residents.
LPA Day obtained a Memo from R#1 physician that indicated that Ativan can be used at the dosages of 2 to 6 mg daily with the maximum of 10 mg daily and does not feel that the 2.5 mg dosage would led to the demise of R#1.
LPA did not observe deficiencies therefore no citations were issued at this time. LPA requested the death certificate from the facility.

An exit interview was conducted, a copy of the Report were provided to Administrator Stephanie Brynjolfson .
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle DayTELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024
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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