306004350-10-31-2023-22-AS-SSAS-CX62YT-20231031174917

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004350
Report Date: 10/31/2023
Date Signed: 10/31/2023 09:20:05 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/04/2020 and conducted by Evaluator Joseph Alejandre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20201204081224

FACILITY NAME:	SILVERADO SENIOR LIVING - SAN JUAN CAPISTRANO		FACILITY NUMBER:	306004350
ADMINISTRATOR:	BROWN, DEBORAH		FACILITY TYPE:	740
ADDRESS:	30311 CAMINO CAPISTRANO		TELEPHONE:	(949) 240-0550
CITY:	SAN JUAN CAPISTRANO	STATE: CA	ZIP CODE:	92675
CAPACITY:	0	CENSUS: 0	DATE:	10/31/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:			TIME COMPLETED:	09:05 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff failed to meet resident's needs resulting in dehydration.
Facility does not have adequate staffing to meet the needs of the residents.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Joseph Alejandre completed the investigation into the allegations listed above. The facility is closed and no longer operating so the LIC 9099 is being sent to the address on record for the Licensee via certified mail.

The investigation into the allegation revealed the following. It was reported that a resident (R1) was sent to the hospital due to dehydration. No details other than a first name were provided. The Agency (CCL) received 8 Special Incident reports for November 2020 from the facility and 6 Special Incident reports for December 2020. One of the reports from December 2020 reported that R1 suffered an unwitnessed fall and was sent to the hospital to be evaluated. The Administrator reported that R1 was sent to the hospital and admitted due to possible head injury. The Administrator reported that R1 returned a few days later with no new orders. The Administrator and Health and Wellness Coordinator reported after R1 returned to the facility, it was confirmed by the hospital that R1 suffered lacerations on their knee and a bruise under their left eye from the fall but was not diagnosed as being dehydrated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

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 3

Control Number 22-AS-20201204081224

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SILVERADO SENIOR LIVING - SAN JUAN CAPISTRANO	FACILITY NUMBER: 306004350
	VISIT DATE: 10/31/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

R1 was kept overnight for observation to make sure they did not have a serious head injury. R1 could not be interviewed at the time of the complaint due to Covid-19 restrictions and has since passed away so no interview was conducted. There is no documentation available other than the original incident report since the facility is now closed. There is no evidence to support the allegation. Based on the evidence available, the allegation, staff failed to meet resident’s needs resulting in dehydration, is deemed unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

The investigation into the allegation, facility does not have adequate staffing to meet the needs of the residents, revealed the following. It was reported that Resident 2 (R2) developed a pressure injury because of a lack of staff to properly monitor the resident. The only information provided was R2’s first name. There were 2 residents that had a similar first name, it is unknown which resident the allegation referred to. LPA reviewed R2 and R3 facility records. R3 had no reports of a pressure injury. R2 had a mention of a pressure injury on their progress notes. The entry for 11/19/2020 stated, “Resident discharged from HomeHealth wound care today.”. The Administrator and Staff reported that R2 and R3 are not on hospice or home health care at this time. Due to Covid-19 restrictions R2 and R3 could not be interviewed and have since passed away. It was reported that Resident 4 (R4) had to wait extended periods of time before his call light is answered. The Administrator reported that R4 no longer resides at the facility and his RP did not provide their new address or contact information. The call system at the facility does not track response time and there is no call log tracking the calls for assistance. There is no facility record to verify the report of delayed response for calls for help. It was reported that there are not enough caregivers to meet the needs of the residents and there were 27 residents in memory care with two caregivers assigned to memory care. A review of the December 2020 facility schedule shows that for the am shift from 6:00 am to 2:30 pm there was an average of 8 caregivers working each day, for the pm shift from 2:00 pm to 10:30 pm there was an average 7 caregivers working each day and for the overnight shift from 10:00 pm to 6:30 am there was an average of 3 caregiver working. The Administrator reported that there is always at least one med-tech on duty overnight and 2 med-techs for the am and pm shifts. The facility census at the time of the 10-day visit was 71. The Administrator reported that there are usually 3 caregivers in memory care for am and pm shifts and overnight there is one because most residents are asleep. The Administrator reported that overnight there are 3 caregivers and 1 med-tech so if any assistance is needed there are enough staff to meet the needs of the residents.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20201204081224

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SILVERADO SENIOR LIVING - SAN JUAN CAPISTRANO	FACILITY NUMBER: 306004350
	VISIT DATE: 10/31/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

During the day at the facility there are at least 7 caregivers and 2 med-techs for the whole facility including memory care. It is only at night that the number of caregivers decreases to 3. This is a reasonable number of staff based on the census of 71. The facility averages 7 incidents reports a month for November and December 2020 which is similar to facilities of the same size. There is no evidence to support the allegation. Therefore the allegation, facility does not have adequate staffing to meet the needs of the residents is deemed unsubstantiated. 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.

The LIC 9099 is being sent to the last known address of the Licensee via certified mail.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3