306005692-6-2-2022-22-AS-LADS-CGZUY9-20220805155934

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005692
Report Date: 06/02/2022
Date Signed: 06/02/2022 01:40:48 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
02/22/2022 and conducted by Evaluator Albert Marin

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220222110011

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:	10:00 AM
MET WITH:	Administrator Dwight Dunagan		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Resident sustained multiple falls while in care.
Staff did not respond timely to a resident's alerts

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Albert Marin and Celine De Perio made an unannounced visit to this facility. LPAs met with Administrator (AD) Dwight Dunagan and stated the purpose of this visit.

On allegation that resident sustained multiple falls while in care, the following are the findings. Resident 1 (R1) was admitted in the facility on January 24, 2022. On admission, R1 was observed agitated that required transfer to hospital for further evaluation and management. R1 came back inthe facility on February 2, 2022. On February 7, 2022, R1 was found on the floor with skin tear; February 9, 2022 R1 had a witnessed fall with reopened skin tear; and February 17, 2022, R1 had a witnessed fall with no apparent injuries. R1 was checked and monitored after each incident. On February 18, 2022 R1 triggered a tag alarm. R1 was observed on the floor and evaluated to have suspected head injury. R1 was transferred to the hospital for further evaluation and management. 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 on 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-20220222110011

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 staff did not respond timely to a resident's alerts the following are the findings. Resident 1 (R1) was admitted in the facility on January 24, 2022. On admission, R1 was agitated. Staff evaluated resident and determined the need to transfer resident to hospital for further evaluation and management. On February 2, 2022, R1 was discharged back to the facility. Since then R1 had three fall incidents wherein R1 sustained skin tear. Staff evaluated the resident and administered first aid treatment when necessary, and placed resident under observation. On February 18, 2022 R1 had an unwitnessed fall. Staff evaluated the resident and determined the need to transfer resident to hospital for further evaluation and management. 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.

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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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