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25 | Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced Case Management - Deficiencies visit to Silverado Senior Living - Newport Mesa. During the course of conducting a complaint investigation visit with Complaint Control Number: 22-AS-20230502140537 LPA Velazquez conducted a review of resident records. LPA Velazquez observed the most recent Medical Assessment for Resident (R) #1 documented a date of exam as August 2, 2021 and R1 has a diagnosis of Dementia which was confirmed by Director of Health Services Ashley Guerra, R.N. LPA Velazquez observed the most recent Medical Assessment for R3 documented a date of exam as May 3, 2022 and R3 has a diagnosis of Dementia.
Throughout the review of resident records LPA Velazquez also observed documentation of multiple incidents for R1, R2, and R3 which Administrator Heather Younan and Director of Health Services Ashley Guerra, R.N. confirmed, yet these incidents were not reported to Licensing pursuant to Title 22 Regulation. Administrator Heather Younan and Director of Health Services Ashley Guerra, R.N. confirmed these resident incidents were not reported to Licensing as required.
Deficiencies cited under California Code of Regulations Title 22, Division 6, Chapter 8. An exit interview was conducted with Administrator Heather Younan and Director of Health Services Ashley Guerra, R.N. and a copy of this report along with the appeal rights, LIC 811, and LIC 9098, were provided at the time of this visit. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
05/26/2023
Section Cited
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7 | Care of Persons with Dementia. Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: Each resident with dementia shall have an annual medical assessment (MA) as specified in Section 87458...
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7 | Licensee to ensure all residents with Dementia have an annual Medical Assessment pursuant to Regulation. Licensee to submit written proof of an updated MA for R1 and R3 to LPA by POC due date. |
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14 | both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by: based on record review & interview the licensee did not ensure R1 & R3 had an annual MA. This poses a potential risk to the health & safety of residents in care. | 8
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14 | Licensee to submit a written statement to LPA indicating they have read this Regulation and how exactly they intend to adhere to it by POC due date. |
Type B
05/12/2023
Section Cited
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7 | Reporting Requirements. Each licensee shall furnish to the licensing agency...including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. | 1
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7 | Licensee to submit Incidents Reports to Licensing for R1 - R3 to LPA by POC due date. |
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14 | Any incident which threatens the welfare, safety or health of any resident...resident. This requirement is not met as evidenced by: based on record review & interview the Licensee did not submit Incident Reports for R1, R2, & R3 as required. This poses a potential risk to the health & safety of residents in care. | 8
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14 | Licensee to submit a written statement to LPA indicating they have read this Regulation and how exactly they intend to adhere to it by POC due date. |