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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603267
Report Date: 06/03/2022
Date Signed: 06/03/2022 04:40:45 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
04/12/2022 and conducted by Evaluator Nune Margaryan
COMPLAINT CONTROL NUMBER: 28-AS-20220412094959
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: 56DATE:
06/03/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH: Rangel-Gutierrez Selene Director of Health Care ServicesTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Resident sustained unexplained injury while in care
Facility has insufficient staffing to meet the residents’ needs
Due to lack of supervision, the residents sustained falls while in care
Facility overcharged resident
Staff failed to provide a comfortable environment for residents in care
Facility staff failed to assist residents in a timely manner
Facility is not allowing visitors inside the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced subsequent complaint visit regarding the above stated allegations. LPA met with Selene Rangel and explained the reason for the visit.

The investigation consisted the following: During the initial visit conducted on 04/22/22 LPA Margaryan inspected the facility including residents’ rooms, tested the signal system, obtained a copies of the staff roster, residents roster, other relevant documents and interviewed Administrator, Staff ( S1) to Staff 6 (S6) and Resident 2 (R2) to Resident 6 (R6). LPA was not able to interview Resident 1 (R1) because R1 moved from the facility on 03/25/22.

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Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
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-20220412094959
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: 06/03/2022
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The investigation revealed the following:

Regarding the allegation that “ Resident sustained unexplained injury while in care” and “ Due to lack of supervision, the residents sustained falls while in care” It was alleged that Resident 1 (R1) sustained an unexplained injury on her left breast and several times some of the residents sustained falls.
To investigate allegations LPA interviewed administrator, staff, residents. Administrator and staff denied the allegations. They stated that staff noticed that R1 had a bruise on their left breast, but not due to lack of supervision.

Interviewed staff indicated that R1 was very active and always move, push items everywhere: furniture, flower’s pots, clothing from other residents room. R1 often move / push residents on wheelchair, thinking helping them. It possible that moving / pushing items around cause bruises on R1 breast.

Administrator stated that staff have reported observing bruising on R1’s breast and this incident is properly documented and reported to CCL (SIR dated on 10/28/2021). On 10/27/2021 R1 was visiting with daughter and complained of discomfort to left breast. Upon further assessment noted discoloration purple and pink in color to R1’s breast. No swelling noted at that time and R1 had no pain. Per DHS Rangel Selene (S1) R1 didn’t know how it happened. Caregiver (S2) stated R1 noted to be touching and pulling on breast over last day but no discoloration noted when S2 assisted R1 to dress for bed. Upon noticing the bruise/discoloration on R1’s left breast S1 contacted to Dr. Bahsoura after assessment and doctor ordered bilateral breast ultrasound and lab work for further assessment for unusual discolored area to left breast. Doctors visit was scheduled on 10/28/21 at 3:30 pm. Resident’s daughter was present at the time of visit. Facility staff follow to doctors order and the next few days staff observed that discoloration of the R1’s left breast was resolved. Lab and ultrasound results came back within normal range. There were “no focal lesions or other abnormalities”.

Staff also indicated that when they notice anything out of the ordinary such as bruising it is immediately documented and reported to Administrator. Administrator and all interviewed staff and residents denied that some of the residents sustained falls several times at the facility. DHS stated that residents have a full body check 2 - 3 times a week during shower. Also, caregivers will address if any injuries observed during their shift providing care to residents. Staff will be noticed if any bruises or injuries of the residents sustained falls.

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SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20220412094959
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: 06/03/2022
NARRATIVE
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Regarding the allegations that “Facility has insufficient staffing to meet the residents’ needs” and “Facility staff failed to assist residents in a timely manner” It was alleged that anyone tries to contact the facility after hours no one answers the phone, residents with dementia walk outside the facility and go back and forth from one building to another building and none of the staff members are present to supervise them and whenever the residents call the staff for assistance it takes them 20 minutes to get back to the residents.
Administrator and staff denied the allegations. Administrator and staff stated that there is always sufficient staff at the facility to assist residents and always someone at the front to answer the phone. Administrator also indicated that family members have her phone number and in case of emergency they can contact
her. LPA observed that facility is consist of 3 buildings: Terrace Park – Early stage of dementia,
Canyon View – Middle, late stage of dementia and Office building. Administrator stated that usually residents stayed in their neighborhood but because some of them are friends, sometimes they are visiting to each other. Interviewed staff denied that residents are going back and forth without supervision. There is always enough staff at the facility 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.
At the time of visit LPA randomly choose the residents room and check on the call / signal system. It took 3 to 5 min that staff respond the calls. Interviewed residents denied the allegation. They stated that staff assisting them on timely manner, and they don’t have any complains about this matter.

Regarding the allegation that “Facility overcharged resident” it was alleged that on an unknown date the facility overcharged R1 in the amount of $600 and told the RP that they charged the resident for incontinence needs.
Administrator stated that R1 was charged for incontinence care for the month of February 2022 by Corporate office while facility does bowel and bladder monitoring to see if R1 is really is incontinent. She also indicated that amount was $565.00 not $600.00. Administrator provide the copies of emails that was sent to the Senior accountant at the Corporate Office on 02/07/22 requesting to not charge the resident before administrator will let them know the end of the month if R1 is incontinent and would need to pay the incontinence fees. Statements of February 2022 and March 2022 for R1 was provided. LPA reviewed the statements and observed that $565.00 was removed from the February statement and refunded to R1 account. LPA spoke with R1's doughier on 4/22/2022, who confirm that facility refund the incontinence fees. Continue 9099C
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20220412094959
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: 06/03/2022
NARRATIVE
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In regards the allegation that "Staff failed to provide a comfortable environment for residents in care" it was alleged that there are 5-8 dogs at the facility that belong to the residents, and they wander everywhere at the facility. The RP stated that on an unknown date she found a dog sitting under her mother’s bed. The RP stated that the facility’s dining room is extremely crowded.

At the time of visit LPA observed 3 dogs at the facility, in the office building. Interviewed staff and residents denied the allegation. They stated that there are 3 dogs and dogs not wandering everywhere at the facility.
Interviewed staff indicated that dogs are friendly, and all staff and residents like them and most of the time dogs are in the Administrator’s office. LPA didn’t observe any dogs in other buildings or in residents room. Interviewed staff and residents stated that 3 dogs not belong to residents.
LPA reviewed the facility's “Resident and Family Handbook” which indicated that pets are welcome at the facility and administrator approves all pets for the community and may revoke approval at any time. Facility “Resident and Family Handbook” was provided to all residents and family members with Residency Agreement. LPA reviewed the facility's philosophy on pets and policies and procedures.
A review of the facility's pet records documented that the animals are current with their license, immunization record, animal identification. Interviewed staff indicated that the dining room not extremely crowed. There is not only one dining room at the facility. LPA observed that facility has 2 main dining rooms, 2 private and 2 bistro areas that can be used as a dining area when needed. Interviewed residents indicated that dining rooms were not crowded. Staff and residents stated no one complains that dining rooms are crowded. Staff and residents interviews do not corroborate this allegation.

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SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20220412094959
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: 06/03/2022
NARRATIVE
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In regards the allegation that "Facility is not allowing visitors inside the facility" It was alleged that facility is still not allowing visitors inside the facility, and they tell everyone it’s because of the pandemic. The facility only allows visitors outside the facility for 2 hours in morning and 2 hours in the afternoon.
LPA observed the facility visitation documents and observed that visitation hours could be changed, if facility has a Covid cases at the facility. Visitation hours can be limited to 2 hours at AM and 2 hours at PM. Facility provided the documentarians to LPA which include the dates, hours of visitations and the reason why the changes were made. Administrator stated that residents and family members / responsible parties were informed about changes. At the time of visit LPA observed at the front desk sign that shows visitation hours 9am - 5pm Monday - Sunday.

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 HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5