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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005652
Report Date: 09/26/2024
Date Signed: 09/26/2024 03:29:49 PM

Substantiated


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
06/14/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20220614095130
FACILITY NAME:SILVERADO BREA LLCFACILITY NUMBER:
306005652
ADMINISTRATOR:VALENCIA, VANESSAFACILITY TYPE:
740
ADDRESS:149 W LAMBERT RDTELEPHONE:
(714) 598-2052
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:70CENSUS: DATE:
09/26/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ashiman GillTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility did not safeguard resident property
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility and interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as facility documentation. Regarding the allegation that facility did not safeguard resident property, the investigation revealed the following: Resident was admitted to facility under respite care 05/23/2022-06/01/2022. Per nursing admission evaluation dated 05/23/2022, the resident admitted with hearing aids and evaluation indicated that resident "can hear adequately with devices." Resident was transferred to the hospital and per witness, the hearing aids have not been returned back to responsible party to date. Facility staff is unaware of whereabouts of the hearing aids. Based on interviews conducted and record review, the preponderance of evidence standard has been met. Therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to facility along with appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
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 4
Control Number 22-AS-20220614095130
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2024
Section Cited
CCR
87468.1(a)(12)
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To wear their own clothes; to keep and use their own personal possessions, including their toilet articles; and to keep and be allowed to spend their own money. This req is not being met as evidenced by:
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Licensee to submit a statement of understanding of the regulation to LPA by POC due date.
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Based on interviews conducted and record review, Licensee failed to ensure resident kept their personal possessions. Facility did not retun hearing aids to resident after discharge. 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: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
06/14/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20220614095130

FACILITY NAME:SILVERADO BREA LLCFACILITY NUMBER:
306005652
ADMINISTRATOR:VALENCIA, VANESSAFACILITY TYPE:
740
ADDRESS:149 W LAMBERT RDTELEPHONE:
(714) 598-2052
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:70CENSUS: 33DATE:
09/26/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ashiman GillTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Resident’s needs are not being met
Resident was not provided medical attention in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility and interviewed staff and witness as well as reviewed and obtained pertinent documentation such as facility documentation. Regarding the allegations that resident’s needs are not being met and resident was not provided medical attention in a timely manner, the investigation revealed the following: Resident 1 (R1) was admitted into facility under respite care from 05/23/2022-06/01/2022. Facility documentation indicated resident was being observed regularly by staff and the resident was at baseline. On 06/01/2024, facility documentation indicates the resident was sent out to St. Jude for knee pain. Facility LVN indicates sending the resident out. Witness indicates facility did not call 911 rather resident's responsible party was the one to call. Based on interviews conducted and record review, the department is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have CONTINUED ON LIC 9099C DATED 09/26/2024
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20220614095130
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: 09/26/2024
NARRATIVE
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happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4