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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004351
Report Date: 09/17/2020
Date Signed: 09/18/2020 03:43:04 PM



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
04/29/2020 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200429162605
FACILITY NAME:SILVERADO SENIOR LIVING - NEWPORT MESAFACILITY NUMBER:
306004351
ADMINISTRATOR:LIGHT, ERINFACILITY TYPE:
740
ADDRESS:350 W BAY STTELEPHONE:
(949) 631-2212
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:82CENSUS: 64DATE:
09/17/2020
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Breanna PritchardTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility failed to meet resident's needs.
Facility failed appraise and reappraise resident.
Facility failed to seek timely medical services.
Facility failed to obtain a medical assessment prior to admittance.
Facility failed to report suspected abuse.
Facility failed to implement fall prevention plan.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre contacted the facility via telephone to deliver findings on a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA identified himself and discussed the purpose of the call and the elements of the allegations with Breanna Prichard, Assistant Director of Health Services. During the course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation to include, physician report dated 11/03/2017, Hoag Hospital medical records dated 11/04/2017 and 11/10/2017, and facility notes dated 11/01/2017-11/10/2017. The investigation revealed the following: Resident 1 (R1) was admitted into the facility on 11/01/2017 after living alone. Per documentation obtained, a Silverado at Home Social Worker assessed R1 on four different occasions at their home prior to being admitted. Multiple Adult Protective Services reports had been filed due to health and safety concerns regarding the R1’s health. The Comprehensive Geriatric Tool dated 10/12/2017 indicated R1 had been admitted to Chapman Medical Center in 2015 under a 5150-hold due to confusion, paranoia, and self-neglect. (Continued).
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2020
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 10
Control Number 22-AS-20200429162605
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 - NEWPORT MESA
FACILITY NUMBER: 306004351
VISIT DATE: 09/17/2020
NARRATIVE
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The Social worker recommended psychiatric treatment to treat paranoia and hallucinations as well as oversight by a neurologist to treat Dementia. Documentation and interviews report R1 was very anxious, emotional, and combative. The facility’s appraisal conducted on 10/26/2017 failed to thoroughly address the noted behaviors, despite the prior documentation from the social worker’s assessment indicating a need to address these concerns. The facility staff stated R1 would be under “Behavior Mapping” which is a facility created program implemented to document and track resident behaviors every hour. However, behavior mapping worksheet dated 11/01/2017 indicates the resident was being observed between 8 to15 hours out of each 24 hour periods. The physician report was completed on 11/03/2017, two days after being admitted to the facility. The physician assessment indicated R1 was exhibiting significant behaviors and was a significant fall risk and fall precautions were necessary due to osteoarthritis.

On 11/03/2017 at approximately 4:45 AM, it was reported R1 deliberately slid off their bed and sat down on the floor while in the presence of a 24-hour care companion. R1 immediately started screaming that their arm was broken. Due to R1’s yelling, the care companion immediately contacted the facility nursing station for assistance. Two nurses (LVNs) responded and assessed the resident via a Range of Motion (ROM) assessment, however, did not call 911. No plan was put in place to address R1’s fall after it was initially reported until after contacting R1’s physician. Per R1’s care companion, R1 was not given any pain treatment by the assessing LVN’s at the time of the incident. The physician was notified of R1’s fall at approximately 9 AM via fax and an order for Tylenol was given. At approximately 9 PM R1 refused to complete a ROM for the facility LVNs. The following morning the resident was observed by the facility staff to have a bruise on their arm and was observed guarding their upper arm. R1’s physician was notified via fax and an order for X-ray was given After receiving R1’s X-ray results, the physician ordered R1 to be transferred to Hoag Hospital to be evaluated, more than 24 hours after the incident. R1 returned the same day with a diagnosis of a fractured humeral neck on the upper right shoulder.

The nurse admission record dated 11/04/2017 indicated R1 had an unsteady gait and was a two-person assist. The Nursing admission record did not include a written plan of care to address R1’s change in condition following R1’s fracture diagnosis. The nursing admission record dated 11/04/2017 was not completed in participation with the resident and/or their responsible party. No re-appraisal was completed upon return from the hospital to address R1’s fall concerns despite R1’s physician report indicating the fall risk and behaviors, as well as the fracture diagnosis. (Continued).
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 10
Control Number 22-AS-20200429162605
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 - NEWPORT MESA
FACILITY NUMBER: 306004351
VISIT DATE: 09/17/2020
NARRATIVE
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The facility did not have a plan in place or any interventions to mitigate falls. While the facility offers varied activities for its residents, including activities for Sundowning, it is unclear if the resident was able to join in the activities.

On 11/05/2017 R1 was noted per facility staff notes to have said that they think someone hurt them but didn’t know and was heard stating “What the hell happened to my arm? I think someone broke it, but I don’t know.” The facility did not report the suspected abuse to the Department or Long-Term Care Ombudsman. The Administrator stated that R1 was confused as to what happened to their arm due to a diagnosis of Dementia and that the claim of somebody hurting their arm was not credible as there was a witness to the incident. The facility states they did not believe an abuse report was necessary as R1 intentionally slid off the bed. On 11/09/2017 at 4:45 AM, R1 was found on the floor for a second time by facility staff, this time after an unwitnessed fall. Staff reported R1 was complaining of leg and hip pain and was screaming. R1 was non-compliant with the LVN’s assessment and was unable to extend their left leg beyond 90 degrees. R1 was provided Tylenol by facility staff and was placed back to sleep at 5:45 AM. At 9 AM R1 attended a previously scheduled physician appointment and was provided an order for an X-ray after R1 complained of pain to their leg and hip. The X-ray was not conducted until approximately 7:30 PM at which time it was revealed that R1 had a fractured hip. R1 was transferred to Hoag Hospital around 1:45 AM on 11/10/2017, 21 hours after the resident was discovered on the floor. Following the second fall, R1 moved out of the facility on 11/10/2017.

Based on documentation reviewed and interviews conducted the preponderance of evidence standard has been met, therefore, the following allegations: facility failed to meet resident’s needs, facility failed to implement fall prevention plan, facility failed to obtain a medical assessment prior to admittance, facility failed to report suspected abuse, facility failed to appraise and re-appraise resident, facility failed to seek timely medical services are determined to be Substantiated.

The following is being cited per California Code of Regulations, (Title 22, Division 6, Chapter 8).
A civil penalty is pending determination, per H&S Code Section 1569.49(e).

An exit interview was conducted with Breanna Pritchard via telephone and a copy of this report along with attached citations and Licensee/Appeal Rights (LIC 9058 01/16) was provided to Breanna Pritchard via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 10
Control Number 22-AS-20200429162605
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 - NEWPORT MESA
FACILITY NUMBER: 306004351
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/18/2020
Section Cited
CCR
87465(g)
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87465(g)Incidental Medical and Dental Care- The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not being met as evidenced by:
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Licensee agrees to conduct training to staff on calling emergency services and forward proof to LPA by POC due date.
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Based on interviews and record review, Licensee did not ensure 911 was called after R1 sustained two injuries at the facility. Resident sustained a humeral neck fracture on the upper right shoulder on 11/03/2017 and a hip fracture on 11/09/2017. Emergency services were not called and in both cases the resident’s injury was not addressed for at least 21 hours after the incident. This poses an immediate health and safety risk to residents in care.
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Type B
09/25/2020
Section Cited
CCR
87458(a)
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87458(a) Medical assessment - Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not being met as evidenced by:
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Licensee agrees to submit a statement of understanding of the regulation and forward proof to LPA by POC due date.
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Based on record review, Licensee did not ensure R1 had a current physician report prior to admittance into the facility. R1’s physician report was dated 11/03/2017, two days after admittance into the facility. This poses a potential health and safety 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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 10
Control Number 22-AS-20200429162605
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 - NEWPORT MESA
FACILITY NUMBER: 306004351
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2020
Section Cited
CCR
87211(c)
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87211(c) Reporting requirements - Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement is not being met as evidenced by:
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Licensee agrees to provide staff training on abuse reporting and forward proof to LPA by POC due date.
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Based on interviews conducted, Licensee did not ensure suspected physical abuse is being reported to Licensing as well as the Long-Term Ombudsman. R1 made two statements alleging abuse and Licensee did not report to required agencies. This poses a potential health and safety 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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 10
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
04/29/2020 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200429162605

FACILITY NAME:SILVERADO SENIOR LIVING - NEWPORT MESAFACILITY NUMBER:
306004351
ADMINISTRATOR:LIGHT, ERINFACILITY TYPE:
740
ADDRESS:350 W BAY STTELEPHONE:
(949) 631-2212
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:82CENSUS: 64DATE:
09/17/2020
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Breanna PritchardTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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9
Staff engaged in false statements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre contacted the facility via telephone to deliver findings on a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA identified himself and discussed the purpose of the call and the elements of the allegations with Breanna Pritchard, Assistant Director of Health Services. During the course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as physician report dated 11/03/2017, Hoag Hospital medical records dated 11/04/2017 and 11/10/2017, and facility notes dated 11/01/2017-11/10/2017.

Regarding the allegation that staff engaged in false statements due to concern with fraudulent charting as the nursing notes are out of order, the investigation revealed the following: Facility nursing notes reviewed by the Department were observed to be out of sequential order. The Administrator states that charting is sometimes done out of order when there is not enough time to do charting during the shift as well as new sheets of paper used, thus making it appear as if they are out of order. (Continued).
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 10
Control Number 22-AS-20200429162605
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 - NEWPORT MESA
FACILITY NUMBER: 306004351
VISIT DATE: 09/17/2020
NARRATIVE
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The Director of Health Services confirms that charting may not be done in real time due to changing workloads. The Administrator states the issue has since been resolved since 2017 and the facility has a new system. Therefore, the allegation 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.

An exit interview was conducted with Breanna Pritchard via telephone and a copy of this report was provided to Breanna Pritchard via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2020
LIC9099 (FAS) - (06/04)
Page: 7 of 10
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
04/29/2020 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200429162605

FACILITY NAME:SILVERADO SENIOR LIVING - NEWPORT MESAFACILITY NUMBER:
306004351
ADMINISTRATOR:LIGHT, ERINFACILITY TYPE:
740
ADDRESS:350 W BAY STTELEPHONE:
(949) 631-2212
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:82CENSUS: 64DATE:
09/17/2020
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Breanna PritchardTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
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9
Caregivers are not properly trained.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre contacted the facility via telephone to deliver findings on a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA identified himself and discussed the purpose of the call and the elements of the allegations with Breanna Pritchard, Assistant Director of Health Services . During the course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as physician report dated 11/03/2017, Hoag Hospital medical records dated 11/04/2017 and 11/10/2017, and facility notes dated 11/01/2017-11/10/2017.

Regarding the allegation that caregivers are not properly trained, the investigation revealed the following: Although care companions from outside agencies do not fall under Title 22 regulations for training, facility provided proof of Dementia trainings for Staff 1 and 2. Therefore, the allegation is deemed UNFOUNDED meaning that the allegation, was false, could not have happened and/ or is without a reasonable basis. (Continued).
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 8 of 10
Control Number 22-AS-20200429162605
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 - NEWPORT MESA
FACILITY NUMBER: 306004351
VISIT DATE: 09/17/2020
NARRATIVE
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An exit interview was conducted with Breanna Pritchard via telephone and a copy of this report was provided to Breanna Pritchard via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2020
LIC9099 (FAS) - (06/04)
Page: 9 of 10
Control Number 22-AS-20200429162605
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 - NEWPORT MESA
FACILITY NUMBER: 306004351
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/19/2020
Section Cited
CCR
87464(f)(1)
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87464(f)(1) Basic Services - Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c). This requirement is not being met as evidenced by:
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Licensee agrees to submit a detailed written plan on ensuring resident’s basic needs will be provided and forward proof to LPA by POC due date.
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Based on record review and interview, Licensee did not ensure care and supervision was provided to R1. R1 fell two times in nine days and was deemed a fall risk per physician assessment dated 11/03/2017. Facility failed to implement a fall prevention plan. This poses an immediate health and safety risk to residents in care.
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Type A
09/19/2020
Section Cited
CCR
87463(a)
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87463(a) Reappraisals - The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition…. This requirement is not being met as evidenced by:
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Licensee agrees to conduct a retraining of staff regarding reappraisals due to a change of condition and forward proof to LPA by POC due date.
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Based on observation and record review, Licensee did not ensure a reappraisal was conducted once there was a change in condition. R1 transferred to a hospital and was accepted back into the facility without a re-assessment. This poses an immediate health and safety 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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2020
LIC9099 (FAS) - (06/04)
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