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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005652
Report Date: 08/11/2021
Date Signed: 08/11/2021 04:13:48 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LLCFACILITY NUMBER:
306005652
ADMINISTRATOR:KAUTEN, MARIAFACILITY TYPE:
740
ADDRESS:149 W LAMBERT RDTELEPHONE:
(714) 598-2052
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:70CENSUS: 30DATE:
08/11/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:19 AM
MET WITH:Directors Izze Perez and Arienne GhammangneTIME COMPLETED:
04:30 PM
NARRATIVE
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 Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit to the facility for the purpose to follow up on an self reported Incident regarding a Medication error that was received by the department on 08/04/2021. LPA met with Director of Resident Engagement Izze Perez and Administrative Assistant Trish Arnold and discussed the purpose of the visit.

LPA Tirre toured facility with Director of Resident Engagement Izze Perez. During visit LPA toured lobby, dining areas, 1st and 2nd floor resident rooms, bistro areas as well as wellness center. During visit LPA met with Director of Resident Engagement and Administrative Assistant to discuss the Incident Report involving the details in the incident regarding Medication errors for 8 residents in care. During the discussion Director of Health Services Arienne Ghammangne and Regional Vice President of Operations Tana Mcmillon also joined in conversation via speaker phone.

On 8/3/21 it was reported to Director of Health Services and VP of Operations that S1 was not giving residents medications as ordered but was signing as given, upon verification, noted residents medications in the destruction cabinet. Facility initiated an investigation into incident. On 8/4/21 S1 was suspended and on 8/5/21 S1 sent in a emailed letter of resignation to Management.

On 8/5/2021 approximately 8:00 AM LPA Tirre spoke with Silverado's VP of Operations Tana Mcmillion who stated at the time that facility was conducting their own investigation regarding incident S1 at the time had been suspended. VP stated that facility conducted new training regarding Personal rights at facility involving a different incident. VP had mentioned facility's previous Administrator had been let go and facility has been in process of getting a new Administrator. VP received an email from staff regarding S1.which was forwarded to LPA. VP also stated the facility contacted The Department, The residents physicians and families regarding incident. VP stated that residents were being monitored and were stable.
CONTINUED ON LIC 809C DATED 8/11/21
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/11/2021
NARRATIVE
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During today's visit VP of Operations mentioned that facility had another incident regarding Medication errors on 8/10/21 regarding a Nursing student, Resident receive incorrect medication for prostate, No adverse reactions noted, resident remains stable and physician and family was contacted. Physician advised staff to continue to monitor resident. Facility informed West Coast University Instructor, students and on site nurses that Nurses/Staff will be physically present when Nursing Students are passing medications.

During today's visit LPA interviewed staff, reviewed MARs, reviewed medications as well as requested documents.

Based on this review, the following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was given to the facility representative at the time of the visit along with a copy of the LIC 809-D and LIC 811. The right to appeal the following citation was discussed at the time of the exit interview and a copy of the appeal rights was given.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/11/2021
Section Cited

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Incidental Medical and Dental Care- The facility shall assist residents with self administered medications when needed. This requirement is not met as evidenced by S1 failing to follow Physicians orders as prescribed.
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on 8/5/21 to LPA.

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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: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2021
LIC809 (FAS) - (06/04)
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