198603267-2-1-2024-28-AS-LHIS-D26ME7-20240205083216

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603267
Report Date: 02/01/2024
Date Signed: 02/01/2024 12:13:51 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
01/24/2024 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240124130220

FACILITY NAME:	SILVERADO SENIOR LIVING-SIERRA VISTA		FACILITY NUMBER:	198603267
ADMINISTRATOR:	GWINN, VIDA		FACILITY TYPE:	740
ADDRESS:	125 E. SIERRA MADRE AVE		TELEPHONE:	(626) 812-9777
CITY:	AZUSA	STATE: CA	ZIP CODE:	91702
CAPACITY:	87	CENSUS: 58	DATE:	02/01/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Selene Rangel, RN/Director of Health Services		TIME COMPLETED:	12:35 PM

ALLEGATION(S):

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Facility staff did not report changes in a resident's medical condition to their physician, resulting in hospitalization.
Facility did not follow correct reporting requirements.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angelica Rea conducted an initial complaint visit in response to the allegations listed above. LPA met with RN/Director of Health Services, Selene Rangel, who assisted with today's visit.

Regarding the allegation that : Facility staff did not report changes in resident #1's medical condition to their physician, resulting in hospitalization. The investigation consisted of review of resident #1's file, and interview(s) with staff #1, and staff #2. The investigation revealed the following: resident #1 has lived at the facility since 9/29/23. Review of resident #1's file indicates that resident #1 is regularly seen by their physician. LPA observed detailed progress notes for resident #1 for the period of 12/31/23 - 1/20/24. Staff interviewed stated that resident #1 was observed by staff on1/2/24, and noted to have cough and congestion. Staff reported this to resident #1's physician, and resident #1 was seen by their physician on 1/2/24. Resident #1's physician ordered a chest x-ray. Chest x-ray results were obtained on 1/4/24. On 1/18/24, staff reported to resident #1's physician, that resident #1 was observed to have a change in condition.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024

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-20240124130220

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: 02/01/2024

NARRATIVE

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Resident #1 was seen by physician on 1/18/24, and labs were ordered. Facility RN received lab results for resident #1 on 1/20/24, noted abnormal lab results and notified resident #1's physician. Physician ordered resident #1 to be transferred to hospital on 1/20/24. LPA was provided with documentation of chest x-ray, and lab results. Staff interviewed stated that resident #1's responsible party was notified, and provided documentation. Resident #1 was discharged to a skilled nursing facility, following hospitalization and has not returned to the facility. LPA observed that staff are reporting changes in resident #1's medical condition to resident #1's physician.

Regarding the allegation that : Facility did not follow correct reporting requirements. The investigation consisted of review of resident #1's file, and interviews with staff #1 and staff #2. Staff interviewed stated that resident #1's responsible party /Power of Attorney (POA) is always notified regarding changes in resident #1's condition. Facility provided documentation that resident #'1's responsible party was notified regarding recent hospitalization. LPA observed that the facility submitted a special incident report to Community care licensing, as required.

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 conducted, and a copy of the report was provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024

LIC9099 (FAS) - (06/04)

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