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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005652
Report Date: 08/28/2025
Date Signed: 09/16/2025 01:37:46 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
08/19/2025 and conducted by Evaluator RoseMarie Ruppert
COMPLAINT CONTROL NUMBER: 22-AS-20250819122622
FACILITY NAME:SILVERADO BREA LLCFACILITY NUMBER:
306005652
ADMINISTRATOR:ASHIMAN GILLFACILITY TYPE:
740
ADDRESS:149 W LAMBERT RDTELEPHONE:
(714) 598-2052
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:70CENSUS: 49DATE:
08/28/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Ashiman Gill, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident fell due to lack of care and supervision
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to investigate a complaint received in the Regional Office. LPA met with Ashiman Gill, Administrator and explained the purpose of the visit.

It was alleged that a Resident fell due to lack of care and supervision on August 19, 2025. LPA obtained the following documents for Resident #1 (R1): Resident roster, August 2025 staff schedule, Unusual Incident Report for 8/19/2025, Identification and Emergency Information, Physician's Report, Service Plan Detail, Progress Notes, Facility Fall protocol, behavior mapping and additional medical documentation.

LPA conducted a health and safety check on residents in care who looked forward to a facility luau to take place at 12pm-2pm. LPA toured R1's room and observed there were no hazards or obstacles. LPA interviewed R1 who stated they were doing fine and gave LPA a thumbs up sign.
(Continued on LIC 9099-C) ****THIS IS AN AMENDED REPORT****
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
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 2
Control Number 22-AS-20250819122622
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SILVERADO BREA LLC
FACILITY NUMBER: 306005652
VISIT DATE: 08/28/2025
NARRATIVE
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(Continued from LIC 9099)

The Physician's Report dated 1/17/2025 states R1 has a diagnosis of dementia. Upon questioning, R1 could not recall a recent fall that occurred. R1 stated they enjoyed their breakfast but could not recall what they ate for breakfast.

LPA interviewed two of two witnesses, four of four staff and Resident #1 (R1) regarding the fall incident. Two of four staff members were present at the time of the fall. One staff member witnessed R1 sitting on the bed and then R1 losing their balance and falling to the floor. The other staff member heard the fall and headed to the area and the nurse immediately followed.

LPA reviewed video footage and obtained photos of time stamps regarding the incident. Staff interviews indicated R1 had a witnessed fall at 7:42am. Camera footage shows staff member stepping out of the room and within a minute's time, a second staff member and then the nurse are observed going into the room. Staff notified Responsible Party (RP) and paramedics were on-site by 7:57am.

LPA reviewed the documents and an updated assessment was conducted on August 13, 2025 regarding R1. An Unusual Incident Report was filed with the Department by the facility and resident returned on same day. Upon return, a personal 1:1 caregiver was provided to observe R1 from 8pm to 8am and Behavioral mapping of nighttime activities was completed.

Based upon LPA observations, interviews, records and video review the allegation that a Resident fell due to lack of care and supervision is Unfounded. The allegation is false, could not have happened, and/or is without a reasonable basis.

An exit interview was conducted with Ashiman Gill, Administrator, and a copy of this report was provided to the facility.

****THIS IS AN AMENDED REPORT****
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2