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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005652
Report Date: 11/16/2020
Date Signed: 11/16/2020 05:38:41 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
08/18/2020 and conducted by Evaluator Michael Barrett
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200818085523
FACILITY NAME:SILVERADO BREA LLCFACILITY NUMBER:
306005652
ADMINISTRATOR:KAUTEN, MARIAFACILITY TYPE:
740
ADDRESS:149 W LAMBERT RDTELEPHONE:
(714) 598-2052
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:70CENSUS: 27DATE:
11/16/2020
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Executive Director (ED) Maria KautenTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility lacks sufficient staff to meet residents' needs
Facility fails to report incidents
Resident left the facility unsupervised
Facility alert devices are not working and are in disrepair
Facility staff lacks training
Facility does not provide a safe environment for residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Mike Barrett contacted the facility via telephone for the purpose of presenting the findings of the complaint investigation due to COVID 19 and pre-cautionary measures. LPA Barrett identified himself and discussed the findings with Executive Director (ED) Maria Kauten. The following are the findings of the investigation conducted by LPA Barrett, which involved interviews, record review and site observations.
On August 18, 2020, the Department received a complaint alleging that the facility lacks sufficient staff to meet residents’ needs. This complaint is based on information given that there are residents who have suffered falls and that an increase in the number of staff would reduce the number of resident falls in the facility. The facility has a capacity of 70 residents with a current census of 27. Staff at times will call-out from their shifts. LPA requested and reviewed the facility employee schedule for the month of July 2020 and observed that for the AM shift (6:00 AM – 2:00 PM) the facility had one (1) LVN, and four (4) caregivers; the PM shift (2:00 PM – 10:00 PM) scheduled one (1) LVN and four (4) caregivers; the NOC shift (10:00 PM – 6:00 AM) scheduled one (1) LVN and three (3) caregivers.
Continued on page 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael BarrettTELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2020
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 3
Control Number 22-AS-20200818085523
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 BREA LLC
FACILITY NUMBER: 306005652
VISIT DATE: 11/16/2020
NARRATIVE
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Continued from page 1.

LPA conducted interviews with Staff #1 (S1), Staff #2 (S2), Resident #2 (R2) and Witness #1 (W1), in regard to staffing needs. Interviews revealed that when the facility would experience a staff call-out, the shift would immediately be covered. Based on the, aforementioned, schedule and interviews conducted, there is not a preponderance of evidence to show whether the allegation did nor did not occur therefore, it is deemed to be unsubstantiated.

It was alleged that the facility failed to report incidents. It was reported that there were several falls that were not reported to CCLD causing concern for the safety of the residents in care. LPA reviewed incident reports received and recorded in the CCLD database from January 2020 through September 2020 which revealed that the facility was reporting incidents on a regular basis. LPA investigated and cross-referenced several of the dates listed in the complaint as non-reported incidents to CCLD and discovered most to have been reported while others were incidents not required for reporting to the department. It was observed that some of the dates of falls listed in the complaint report could not be verified. Based on file review and interviews conducted, there is not a preponderance of evidence to show whether the allegation did nor did not occur therefore, it is deemed to be unsubstantiated.

It was alleged that a resident left the facility unsupervised. It was reported that Resident #1 (R1) had left the facility through a service door and hitchhiked back to R1's family’s home and was missing for over an hour before being found. LPA conducted a virtual tour of the area where R1 had exited the building onto a non-busy street. LPA conducted interviews with S1, S2, S3, Administrator and R1’s family as well as reviewed R1’s physician’s report, assessment and care plan. Interviews and documentation revealed that R1 was high functioning but suffers from Mild Cognitive Impairment (MCI). R1 also had a cell phone with a Lyft application installed giving R1 access to requesting ride services. The applications was installed by R1’s spouse onto both of their phones, prior to R1 moving into the facility, and was used by R1’s spouse to be able to travel to the facility when visiting. Interviews, observations and document review revealed that R1 had become confused and desired to go home. R1 had requested to be picked up by Lyft services at the facility. R1 exited the facility through a delayed egress door, sounding the alarm, and at the exact time that the Lyft service arrived to pick her up. When the staff arrived following R1’s exit, R1 was not seen. An assessment of residents was immediately conducted and R1 was reported to be missing within 10 minutes and R1’s family had been notified.
Continued on page 3.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael BarrettTELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20200818085523
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 BREA LLC
FACILITY NUMBER: 306005652
VISIT DATE: 11/16/2020
NARRATIVE
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Continued from page 2.

It was at that point that R1’s family had determined that R1 had requested a Lyft driver to pick R1 up and deliver R1 to the family home, which was approximately 15 minutes away. Upon arrival at the family home R1’s family telephoned the facility to report that R1 had arrived safely. R1 was picked up and brought back to the facility without incident and was observed to be unharmed. Based on observations, file review and interviews conducted, there is not a preponderance of evidence to show whether a violation did nor did not occur therefore, the allegation is deemed to be unsubstantiated.

It was alleged that facility alert devices are not working and are in disrepair. LPA toured the facility with the Executive Director via tele-visit and requested a test of the alert devices on the doors as well as the delayed egress door in which R1 had breached and they were observed to be in working order. LPA requested and received documentation showing recent testing completed on all the door alarms for the month of July. The document showed that door alarm tests were completed on 7/6/20, 7/13/20, 7/20/20, and 7/27/20, all of which showed that the doors were in working order. LPA conducted interviews with S1, S2 and S3 who all stated that they are required to have walkie-talkies while on shift and that if/when the door alarms are triggered, an alert is sent over the walkie-talkie requiring them to respond. They all attested that the equipment was working well and did not report having any issues with them. Based on observations, record review and interviews conducted, there is not a preponderance of evidence to show whether the allegation did nor did not occur therefore, it is deemed to be unsubstantiated.

It was alleged that facility staff lacks training. LPA requested and reviewed training for three (3) out of forty (40) staff members picked at random. LPA reviewed the training record of two (2) staff member who have worked less than one year and one (1) staff members who had worked for over one year. The newer staff members training record showed completion of the required 40 hours of in-service and shadowing, while the other staff member’s records revealed completion of the annual training requirement of 20 hours. Based on file review of the three out of forty above-mentioned staff, there is not a preponderance of evidence to show whether the allegation did or did not occur therefore, it is deemed to be unsubstantiated.

This department has investigated this complaint. No violations are being cited at this time.

An exit interview was conducted with Executive Director Maria Kauten via telephone and a copy of this report was provided to ED Kauten via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael BarrettTELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3