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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603267
Report Date: 11/10/2022
Date Signed: 11/10/2022 03:53:26 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
06/24/2021 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210624125839
FACILITY NAME:SILVERADO SENIOR LIVING-SIERRA VISTAFACILITY NUMBER:
198603267
ADMINISTRATOR:GWINN, VIDAFACILITY TYPE:
740
ADDRESS:125 E. SIERRA MADRE AVETELEPHONE:
(949) 240-7200
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY:87CENSUS: 51DATE:
11/10/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Maria Torres TIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Resident not accorded reasonable access to telephones, to both make and receive confidential calls.
Resident not accorded dignity in relationships with staff.
Staff are locking the resident on facility premises.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Wong conducted a “Subsequent” visit to ascertain additional information regarding the above-mentioned allegation(s) and for the purpose of rendering the findings.
LPA met with Administrative Assistant Maria Torres and explained the reason of the visit.

The investigation consisted of the following: On 6/29/21, LPA David Sicairos interviewed Administrator, Director of Health Care Services, Staff #1 (S1) and Resident #1 (R1). LPA obtained copies of R1's file. LPA also toured the facility which included the common areas. On today's visit, LPA Wong interviewed Administrator, Director of Health Care Services via telephone and Staff#1-#2 (S1-2) and Resident#2-#6 in the facility and obtained the documents included resident sign-out log from June 10th to 24th, 2021 and visitors sign in sheet from May 28th to June 26th, 2021.

(Please See LIC 9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 28-AS-20210624125839
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: 11/10/2022
NARRATIVE
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The investigation revealed of the following: In regard to the allegation of " Resident not accorded reasonable access to telephones, to both make and receive confidential calls." LPA interviewed residents and they all denied the allegation and stated that they were able to make phone calls any time they want. There's no restriction for them. LPA also interviewed staff and reported its residents personal right to use the facility phone any time they wanted. Staff also stated that the facility has a wireless phone for residents to use. There's also common phone in the middle of the area for residents to access. The staff reported that R1 also had her own cell phone at that time. R1 can make any phone calls or receive any phone calls that R1 wanted.

In regard to the allegation of " Resident not accorded dignity in relationships with staff." LPA interviewed residents and they all denied the allegation. They all stated that all the staff in the facility are nice and respectful. They treat them very well. LPA interviewed staff and also denied the allegation and reported they never witnessed any staff was disrespectful to the residents in the facility. And all the staff have been trained to be respectful and kind to all residents and guests, basically everyone in the facility.

In regard to the allegation of "Staff are locking the resident on facility premises." The administrator and staff stated that the facility is a secured community/facility for residents safety but the residents are not in person or locked in the facility or something. The administrator stated that as long as someone is able to sign the resident out, the resident is able to go out with their family, friends or whoever signed them out.

Based on statements and interviews conducted with staff, residents and recorded review, 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 conducted. A copy of the report and appeal right was provided to the Administrative Assistant Maria Torres.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
06/24/2021 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210624125839

FACILITY NAME:SILVERADO SENIOR LIVING-SIERRA VISTAFACILITY NUMBER:
198603267
ADMINISTRATOR:GWINN, VIDAFACILITY TYPE:
740
ADDRESS:125 E. SIERRA MADRE AVETELEPHONE:
(949) 240-7200
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY:87CENSUS: 51DATE:
11/10/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Maria Torres TIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Staff are not allowing resident to leave or depart the facility at any time.
Staff are not allowing resident to have visitors during reasonable hours and without prior notice.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Wong conducted a “Subsequent” visit to ascertain additional information regarding the above-mentioned allegation(s) and for the purpose of rendering the findings.
LPA met with Administrative Assistant Maria Torres and explained the reason of the visit.

The investigation consisted of the following: On 6/29/21, LPA David Sicairos interviewed Administrator, Director of Health Care Services, Staff #1 (S1) and Resident #1 (R1). LPA obtained copies of R1's file. LPA also toured the facility which included the common areas. On today's visit, LPA interviewed Administrator, Director of Health Care Services via telephone and Staff#1-#2 (S1-2) and Resident#2-#6 in the facility and obtained the documents included resident sign-out log from June 10th to 24th, 2021.

(See LIC 9099C for continuation)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20210624125839
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: 11/10/2022
NARRATIVE
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The investigation revealed of the following: In regard to the allegation of "Staff are not allowing resident to leave or depart the facility at any time." LPA reviewed the resident sign out log and LPA did not see any visitors sign R1 out from June 10th to July 11th, 2021 when R1 reported friends wanted to take R1 out to lunch before June 24, 2021 but got rejected from the facility to leave the building.

In regard the allegation of "Staff are not allowing resident to have visitors during reasonable hours and without prior notice." LPA also reviewed the visitor sign in sheet. On June 18, 2021, R1's friend name was not on the visitor sign in log. R1's friend was unable to visit R1 on June 18, 2021. LPA reviewed R1's friend name but was able to visit R1 on either June 19th or June 20th, 2021. Therefore, it shown proof that R1 was not allowed visitor at one point. Administrator also mentioned that R1's son did not want one of R1's friend to come and visit R1 at one point.

Based on LPA observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC9099D.

An exit interview is being conducted with Administrative Assistant Maria Torres and a copy of this report is being provided and Appeal Rights were given.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20210624125839
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
11/24/2022
Section Cited
CCR
87468.1(a)(6)
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87468.1 Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6)To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night.
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The administrator will ensure the personal right of residents in all facilities The administrator will retrain staff regarding the personal right and send the staff training log to LPA by POC due date
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This requirement is not met as evidenced by: Based on documents reviewed, R1 was not able to leave or depart from the facility while R1's friend wanted to go out with R1 which posed a potential risk to residents in care
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Deficiency Dismissed
Type B
11/24/2022
Section Cited
CCR
87468.1(a)(11)
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87468.1 Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.
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The administrator will ensure the personal right of residents in all facilities The administrator will retrain staff regarding the personal right and send the staff training log to LPA by POC due date
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The requirement is not met as evidenced by: Based on the documents reviewed, R1's friend was not able to visit on June 18, 21 which posed a potential risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5