198603267-8-26-2022-28-AS-RORN-CHULK3-20220901084849

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603267
Report Date: 08/26/2022
Date Signed: 08/26/2022 12:59:05 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
09/24/2021 and conducted by Evaluator David Sicairos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210924131831

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: 60	DATE:	08/26/2022
		UNANNOUNCED	TIME BEGAN:	12:01 PM
MET WITH:	Selene Gutierrez; Director of Health Care Services		TIME COMPLETED:	01:13 PM

ALLEGATION(S):

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Resident sustained unexplained bruising while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Sicairos conducted an unannounced complaint visit regarding the above stated allegation. LPA met with Selene Gutierrez (Director Of Health Care Services) and explained the reason for the visit.

The investigation consisted of the following: during the initial visit conducted on 09/30/21, LPA obtained copies of Resident & Staff Rosters. LPA also reviewed Resident #1 (R1) file and obtained copies of: Identification and Emergency Information Sheet, Physician's Report, Preplacement Appraisal Information, and Progress Notes. During today's visit, LPA interviewed R1, and Staff #1 - Staff #3.

The investigation revealed the following: in regards to the allegation "resident sustained unexplained bruising while in care", it is alleged that R1 was admitted to the emergency room on 09/23/21 due to a possible clavicle fracture. R1 was examined at the hospital and no fracture was identified, however bruising was observed. Interviews conducted with staff members denied the allegation. Review of R1's Progress Notes dated 09/16/22 indicate R1 began complaining of right shoulder pain. (CONTINUED ON 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

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-20210924131831

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: 08/26/2022

NARRATIVE

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R1's Primary Physician and Responsible Party were notified. R1 continued to be monitored for right shoulder pain for the next few days. On 09/22/21, facility ordered x-ray of right shoulder area which results indicated "mildly displaced medial right clavicle fracture". On 09/23/21, R1's Responsible Party took R1 to Urgent Care for follow up were more x-rays were completed and x-rays came back negative for clavicle fracture. Staff indicated R1 disclosed that she had suffered the right shoulder bruising as a result of swimming exercises. Interview with R1 indicated that she is happy at the facility and has no issues or concerns with staff. R1 indicated she could not recall how she suffered the bruising to her right shoulder area. Staff members interviewed denied causing the bruising. Therefore there was insufficient evidence to corroborate with the allegation.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

LIC9099 (FAS) - (06/04)

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