306005692-6-2-2022-22-AS-MVAO-CG4NJX-20220707103105

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005692
Report Date: 06/02/2022
Date Signed: 06/02/2022 01:48:39 PM

Unsubstantiated

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
01/05/2022 and conducted by Evaluator Albert Marin

COMPLAINT CONTROL NUMBER: 22-AS-20220105170058

FACILITY NAME:	SILVERADO SENIOR LIVING-TUSTIN HACIENDA		FACILITY NUMBER:	306005692
ADMINISTRATOR:	ERIN LIGHT		FACILITY TYPE:	740
ADDRESS:	240 E 3RD STREET		TELEPHONE:	(714) 832-7900
CITY:	TUSTIN	STATE: CA	ZIP CODE:	92780
CAPACITY:	42	CENSUS: 24	DATE:	06/02/2022
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Administrator Dwight Dunagan		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility staff failed to provide requested resident information in a timely manner.
Facility staff mismanaged resident's medication.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPAs) Albert Marin and Celine De Perio conducted unannounced visit to deliver the findings for the complaint filed against this facility last January 5, 2022. LPAs met with Administrator (AD) Dwight Dunagan and stated the purpose of this visit.

On allegation that facility staff failed to provide requested information in the timely manner, it was reported that on December 29, 2021, a verbal query was made on the health status Resident 1; and facility missed to provide information to inquiring party. On file review, On September 10, 2021, the Superior Court ordered stipulation and order regarding settlement for identified parties. Settlement Section 15.2 describes the sole legal authority to act on behalf the resident; and to make financial and medical decisions for Resident 1 (R1). Section 15.8 describes that parties may obtain verbal information from on-site staff regarding resident’s condition. Based on interviews LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. (Continuation in Page 2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert Marin	TELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220105170058

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-TUSTIN HACIENDA	FACILITY NUMBER: 306005692
	VISIT DATE: 06/02/2022

NARRATIVE

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On allegation that facility staff mismanaged resident's medication, the following are the findings. On April 23, 2021, the physician ordered six units of insulin lispro injection to be given by subcutaneously before meals. According to medlineplus.gov Insulin lispro injection products are a short-acting, man-made version of human insulin. Insulin lispro solution is usually injected within 15 minutes before a meal or immediately after a meal. Resident 1 is also receiving insulin Insulin glargine. It is a long-acting, man-made version of human insulin. Based on file review and interviews, In December 29, 2021, Resident got up late. Blood sugar level and insulin lispro were given prior to first meal served; and was recorded around 11:00 AM. The next blood sugar check and dose of insulin was given around the dinner meal service which starts around 5:30 PM. On the course of the investigation, LPA also reviewed medications ordered to be given at bedtime were given around 7:00 PM to 7:30 PM. Based on medlineplus website, both medications have peak blood concentration of about 2 hours following an oral dose. LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED

LPAs Marin and De Perio conducted an exit interview with AD Dunagan and copies of this report were left in the facility.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert Marin	TELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC9099 (FAS) - (06/04)

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