198603267-8-26-2022-28-AS-RORN-CSYLT6-20230620090145

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603267
Report Date: 08/26/2022
Date Signed: 08/26/2022 12:57:46 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/28/2021 and conducted by Evaluator David Sicairos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211228122731

FACILITY NAME:	SILVERADO SENIOR LIVING-SIERRA VISTA		FACILITY NUMBER:	198603267
ADMINISTRATOR:	GWINN, VIDA		FACILITY TYPE:	740
ADDRESS:	125 E. SIERRA MADRE AVE		TELEPHONE:	(949) 240-7200
CITY:	AZUSA	STATE: CA	ZIP CODE:	91702
CAPACITY:	87	CENSUS: 60	DATE:	08/26/2022
		UNANNOUNCED	TIME BEGAN:	09:38 AM
MET WITH:	Selene Gutierrez; Director of Health Care Services		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident sustained an unexplained fracture while in care.
Staff did not seek medical attention for resident while in care.
Resident inappropriately touched another resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Sicairos conducted an unannounced complaint visit regarding the above stated allegations. LPA met with Selene Gutierrez (Director Of Health Care Services) and explained the reason for the visit.

The investigation consisted of the following: during initial visit conducted on 12/29/21 by LPA Tao, LPA toured the facility with the Administrator and obtained copies from Resident #1 (R1) file. During today's visit LPA obtained copies of Staff & Resident Rosters. LPA also obtained copies from Resident #1 (R1) such as Identification & Emergency Info Sheet, Physician's Report, Resident Appraisal, Progress Notes for December 2021, X-Ray Results, and Incident Reports. LPA also interviewed R1, R1's Family Member (FM), and Staff #1 - Staff #3.

The investigation consisted of the following: in regards to the allegation "resident sustained an unexplained fracture while in care", it is alleged that R1 suffered an unexplained fracture to her arm. Interviews with staff and family member confirmed that R1 did suffer a fracture to her right wrist. (CONTINUED ON 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

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 28-AS-20211228122731

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SILVERADO SENIOR LIVING-SIERRA VISTA	FACILITY NUMBER: 198603267
	VISIT DATE: 08/26/2022

NARRATIVE

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Radiology Report dated 12/29/21 indicates "fracture involving the distal metaphysis of the radius with slight impaction and minimal displacement." There is no evidence however, indicating that this fracture happened while at the facility. R1 moved into the facility on 12/23/21 and Progress Notes on that day indicate that "swelling to the wrist" was observed on R1's wrist upon move in. Resident was admitted to Hospice on the same day of move-in, and both hospice and facility were aware of the bruising and continued to monitor the area. Family member interviewed also indicated R1 suffered a couple of falls a few days prior to moving into the facility. R1 also has a history of carpal tunnel syndrome. Therefore there was insufficient evidence to corroborate with the allegation.

In regards to the allegation "staff did not seek medical attention for resident while in care", it is alleged that facility failed to seek timely medical attention for R1 in regards to the wrist fracture. Staff members interviewed denied the allegation. Staff members interviewed indicated wrist bruising was observed and documented upon resident moving in. Staff members interviewed indicated wrist area was monitored daily, and R1 was receiving treatment from hospice agency. This is confirmed via Progress Notes. X-Ray was also requested and completed when bruising did not improve. Family member interviewed also indicated facility staff kept him informed of R1's condition. Therefore there was insufficient evidence to corroborate with the allegation.

In regards to the allegation "resident inappropriately touched another resident in care", it is alleged that another facility resident entered R1's room and tried to touch R1 "inappropriately". Interviews conducted with staff members denied the allegation. Facility staff indicated that on 12/28/21, Azusa Police arrived at the facility to interview R1 as they had received a call that R1 had been touched inappropriately. After interviewing R1, Police left without filing any charges. During today's visit, R1 denied being touched inappropriately by anyone at the facility. Interviews with staff revealed they will redirect residents if they attempt to go into other resident rooms. Additionally, Reporting Party indicated they were not sure if the other resident actually touched R1 inappropriately. Therefore there was insufficient evidence to corroborate with the allegation.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

LIC9099 (FAS) - (06/04)

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