198603267-10-19-2023-28-AS-RORN-CZJLK3-20240116074849

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603267
Report Date: 10/19/2023
Date Signed: 10/19/2023 04:18:30 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
10/13/2023 and conducted by Evaluator Nune Margaryan

COMPLAINT CONTROL NUMBER: 28-AS-20231013083953

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: 57	DATE:	10/19/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Selene Rangel- Gutiererrez		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff did not adequately supervise resident resulting in resident falling.
Resident is dehydrated.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced 10 day complaint visit to investigate the allegations listed above. Upon arriving at the facility, LPA met Rangel-Gutierrez Selene DHS who assisted with the visit. Shortly after Administrator Almavida Gwinn arrived. The reason for the visit was explained.

The investigation consisted of the following: LPA Margaryan toured the facility, obtained a copies of the staff roster, residents roster LPA Margaryan also obtained copies of documents pertaining to Resident#1 (R1) including: Residency Agreement, Admission Record, Identification and Emergency Information, Preplacement Appraisal Information, Resident Appraisal, Physician's Report, Physician Order Review, Neurological Observation Results, Vital Signs Trend, Unusual Incident/Injury Report (SIR) dated 10/05/23. Interviews were conducted with 5 staff (S1 - S5) , 6 residents (R1 - R6) and 1 Family member (F1)

Cont. 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

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-20231013083953

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: 10/19/2023

NARRATIVE

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The investigation revealed the following: Allegation: Staff did not adequately supervise resident resulting in resident falling.

During this investigation, LPA obtained relevant documentation and interviewed staff and residents. Interviewed staff members denied the allegation. Interviewed staff indicated , there is always enough staff at the facility and they provide supervision to all residents in care. R1 does not have a one-on-one caregiver. Based on interviews conducted the findings indicate that resident (R1) sustained a fall on October 05, 2023. The resident was noted by S5 sitting on the floor in the living room. Per S5 a few minutes prior R1 was engaging in activity. S5 immediately notified the LVN. A body check was perform and noted abrasion to the back of the R1's head. Staff help R1 to stand and sit on the coach. LVN clean the abrasion with the saline water and put antibiotic ointment. R1 didn't show any sign of discomfort or pain. R1 was able to walk and ask for the tea and Icecream. Primary doctor and responsible party were notified. Neurological checks conducted. After incident, staff closely monitor the R1 for 2 days and R1 didn't complain of any pains. Residents interviewed were unable to corroborate the allegation. Interviewed residents indicated staff conduct rounds often throughout the entire day. 5 out of 6 residents stated that staff provide adequate supervision. LPA interviewed R1 who just answer "Yes" to all questions .R1 was unable to provide details and/or dates of alleged falls. Interviewed F1 who was visiting R5's at the time of visit stated that there is always enough staff to supervise the residents. At the time of visit LPA observed sufficient staff at the facility. LPA also observed that students from the Nursing School are assisting the residents. Facility staff schedule was reviewed, and it confirm that facility has a sufficient staffing at all the time. There is insufficient evidence to prove the alleged allegation. Documentation reviewed and interviews conducted with staff and residents do not corroborate this allegation.

Cont. 9099C

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20231013083953

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: 10/19/2023

NARRATIVE

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Allegation: Resident is dehydrated. It was alleged that R1 is very dehydrated.

Staff interviewed denied the allegation and stated they have not received any complaints nor concerns in regards the allegation. Staff also stated that sometimes residents refused to eat lunch or dinner, but was reminded to drink fluids. Juice and water are provided during all day. Residents often received water supplies from family as well. R1 is one of them. The facility has six (6) water stations that all residents can access throughout the day. Residents can request fluids at any time of the day, and staff take the fluids to the resident room when requested. Residents interviewed did not corroborate the allegation. Residents indicated staff ensure residents have adequate drinking water. All Interviewed residents stated the facility provided drinks/fluids. They stated never dehydrated. During the visit, LPA observed residents getting water from water stations with plenty of water. LPA observed staff encouraging residents to drink the water.

Based on file reviews, observation and interviews, 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

An exit interview was conducted, and a copy of this report was provided to Rangel-Gutierrez Selene Director of Health Care Services.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC9099 (FAS) - (06/04)

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