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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603267
Report Date: 02/02/2022
Date Signed: 02/02/2022 01:46:08 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
01/24/2022 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220124104257
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: 61DATE:
02/02/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:S-1 and S-2TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Resident illegally evicted.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an initial 10-day complaint visit to investigate the above allegation. LPA met with S-1 and discussed the purpose of today's visit. S-2/Director of Health Services arrived at approximately 11AM.

During this investigation, LPA obtained a copy of the Resident Roster, a copy of the Staff Roster, interviewed S-1, S-2/Director of Health Services, S-3 and R-1's Conservator and reviewed R-1's file and obtained relevant documentation.

Refer to LIC 9099C for the contination of this report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
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 2
Control Number 28-AS-20220124104257
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: 02/02/2022
NARRATIVE
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Allegations: Resident illegally evicted.
During this investigation, LPA interviewed S-1 through S-3 and R-1's Conservator. Interviews revealed that R-1 was hospitalized on 01/24/22 (initiated by R-1). Once R-1 was ready to be discharged, S-2 initially informed the hospital that R-1 was unable to return due to R-1's behavior and risk for hurting others at this facility. S-2 then reconsidered R-1's re-admission to this facility (upon consultation with other facility personnel and R-1's Conservator) for R-1 to return to this facility with one-to-one support in place. Interviews revealed that the need for one-to-one support for R-1 was reasonable due to on-going behaviors. R-1 remained at the hospital and did not return to this facility. Per R-1's Conservator, this facility did not evict R-1 and R-1 was voluntarily moved out due to the monthly costs of this facility and the cost of one-to-one support if put in place (as agreed upon). Interviews revealed that R-1's Conservator came to this facility on 01/30/22 and sent movers on 01/31/22 to remove R-1's belongings. Interviews also revealed that the 30 day move-out notice was waived. Interviews do not corroborate this allegation.

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 was conducted, a copy of this report and Appeal Rights were provided to S-2

SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2