306005693-8-25-2026-22-AS-AORZ-DXZQCT-20260917120341

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005693
Report Date: 08/25/2026
Date Signed: 08/25/2026 11:56:28 AM

Substantiated

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
04/02/2026 and conducted by Evaluator Samer Haddadin

COMPLAINT CONTROL NUMBER: 22-AS-20260402150603

FACILITY NAME:	SILVERADO SENIOR LIVING- NEWPORT MESA		FACILITY NUMBER:	306005693
ADMINISTRATOR:	HEATHER YOUNAN		FACILITY TYPE:	740
ADDRESS:	350 W BAY STREET		TELEPHONE:	(949) 631-2212
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92627
CAPACITY:	82	CENSUS: 66	DATE:	08/25/2026
		UNANNOUNCED	TIME BEGAN:	09:29 AM
MET WITH:			TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Resident sustained unexplained injuries due to staff neglect or abuse.
Staff did not adequately supervise resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sam Haddadin conducted an unannounced complaint investigation visit to the facility regarding the above-mentioned allegations. Upon arrival, LPA met with Administrator (AD) Heather Younan who granted entry into the facility. LPA explained the purpose of the visit.
During the investigation, the Department conducted interviews and reviewed facility records, internal incident reports, Resident 1 (R1)’s Preplacement Appraisal, Residency Agreement, Service Plan, psychological assessment, photographs, hospital records, and hospice records.
Regarding the allegation, “Resident sustained unexplained injuries due to staff neglect or abuse,” facility records documented that R1 was admitted to the facility’s memory care unit in July 2025. R1’s Preplacement Appraisal dated 07/09/2025 identified progressive Alzheimer’s dementia, osteoporosis, significant mobility limitations, and an inability to safely walk more than a few steps without assistance. {****CONTINUE***9099C}

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2026

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 5

Control Number 22-AS-20260402150603

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 SENIOR LIVING- NEWPORT MESA	FACILITY NUMBER: 306005693
	VISIT DATE: 08/25/2026

NARRATIVE

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R1 was identified as non-ambulatory and unstable when walking independently. R1’s Service Plan dated 8/5/2025 stated that R1 required hands-on assistance from staff and might require escorts.
The facility’s internal incident reports documented numerous falls, incidents in which R1 was found on the floor, and injuries for which the cause was not always identified. The Department confirmed 12 fall-related incidents between July and December 2025. Several incidents were unwitnessed, and the corresponding reports did not consistently explain how R1 fell or sustained the resulting injuries.
In July 2025, staff discovered bruising on R1’s left hand and upper arm without an identified cause. In August 2025, R1 was found sitting on the floor near a reclining chair and was later observed with discoloration and apparent discomfort involving her left hand. Furthermore, in October 2025, R1 was assessed following an unwitnessed incident and was observed with a bump on the back of her head. Several days later, R1 was found on the floor with bruising near her lower left buttock. Staff subsequently observed an unexplained bruise on R1’s left forearm. R1 was later found on the floor with a skin tear to her right elbow.
In November 2025, R1 was discovered lying on the floor in a fetal position and was unable to explain how she got there. Staff documented an injury or possible skin tear to R1’s shoulder. R1 was also observed with bruising on her right thigh. During another incident, staff heard a noise and found R1 seated on the floor with her back against a wall and her walker underneath her legs. Another resident reported possibly backing into R1 with a wheelchair. Several days later, R1 attempted to walk around her walker, tripped on the walker’s leg, lost her balance, and fell, resulting in a bump on the back of her head.
On December 4, 2025, R1 was found sitting on the floor following another unwitnessed incident. No injuries were initially identified; however, R1 subsequently complained of right arm pain. An X-ray completed the following day revealed a dislocated right shoulder. R1 was transported to the hospital, where additional testing identified a subarachnoid hemorrhage. R1’s shoulder was manually reset, and she remained hospitalized overnight for neurological observation before returning to the facility. Photographs obtained showed multiple injuries and areas of discoloration.
{***CONTINUE***9099C}

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 22-AS-20260402150603

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 SENIOR LIVING- NEWPORT MESA	FACILITY NUMBER: 306005693
	VISIT DATE: 08/25/2026

NARRATIVE

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Regarding the allegation, “Facility staff did not adequately supervise R1,” the Department reviewed a psychological assessment completed in October 2025. The assessment documented that R1 required extensive redirection and assistance from two people.
The Department interviewed the facility Administrator who confirmed that the facility specialized in memory care and generally assigned one caregiver for every nine residents, in addition to charge nurses assigned to each shift. They acknowledged that R1 experienced a progressive decline and sustained several falls. Staff escorted R1 to and from her room, meals, and activities; however, R1 continued to walk independently with her walker.
Administrator confirmed that R1 experienced 12 fall-related incidents between July and December 2025 and stated that following R1’s first fall, the facility provided R1 with a high-low medical bed and placed a fall mat in her room. However, Administrator acknowledged that the facility did not make any additional changes to R1’s treatment or supervision plan following the second fall or any subsequent falls. They also acknowledged that the facility did not formally discuss placing R1 under one-to-one supervision, did not offer the private-duty caregiving option identified in the Residency Agreement, and did not discuss transferring R1 to a higher level of care. S1 further acknowledged that R1 required assistance from two caregivers. Despite R1’s repeated falls, unexplained injuries, and increased need for assistance, the facility did not formally consider these options. Interviews were conducted with R1’s sons who reported conflicting statements about R1’s care received.
Per Administrator, R1’s family privately arranged for a caregiver to visit R1 and provide companionship. However, the caregiver’s visits varied, lasted approximately four to five hours, and did not occur every day. Therefore, this arrangement did not provide continuous supervision or replace the facility’s responsibility to develop and implement an appropriate supervision plan.
Hospice records documented that R1 began receiving hospice services in December 2025. The records identified repeated falls, wheelchair dependence, and the need for assistance with personal care, and pain related to R1’s right shoulder dislocation. Hospice records stated that R1 could not meaningfully communicate her needs or discomfort and that using a walker had become a safety concern because R1 frequently forgot to use it. {***CONTINUE9099C***}

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 22-AS-20260402150603

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 SENIOR LIVING- NEWPORT MESA	FACILITY NUMBER: 306005693
	VISIT DATE: 08/25/2026

NARRATIVE

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The records further documented that R1 required assistance from two people for transfers.
Based on the information obtained during the investigation, the preponderance of evidence standard has been met; therefore, the allegations that “R1 sustained unexplained injuries, due to staff neglect or abuse” and “Facility staff did not adequately supervise R1” are substantiated.
An immediate civil penalty was assessed per LIC421IM. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f).
Deficiencies are being cited during today’s visit pursuant to Title 22 of the California Code of Regulations. An exit interview was conducted and LIC 811 (Confidential Names) and a copy of this report, along with appeal rights, were provided to AD.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 22-AS-20260402150603

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 SENIOR LIVING- NEWPORT MESA	FACILITY NUMBER: 306005693
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/25/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/26/2026 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	{*THIS IS AN AMENDED REPORT*} “87464(f)(1) Basic services shall at a minimum include care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).” This requirement was not met as	1 2 3 4 5 6 7	The Administrator will review the care and supervision needs of all current residents with repeated falls or significant changes in condition and update their care plans as needed. Staff will be trained on providing supervision
	8 9 10 11 12 13 14	evidenced by interviews and record review showing that R1 required significant assistance resulting in multiple fall and right shoulder dislocation and hemorrhage. this poses an immediate health and safety risk to resident in care	8 9 10 11 12 13 14	consistent with each resident’s assessed needs. Proof of the completed reviews, updated care plans, and staff training will be submitted to the Department by the POC due date.
Type A 08/26/2026 Section Cited CCR 87466	1 2 3 4 5 6 7	{*THIS IS AN AMENDED REPORT*} “87466 The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning….” This requirement was not met as evidenced by interviews and	1 2 3 4 5 6 7	The Administrator will review all current residents for changes in condition and ensure care plans are updated when additional assistance or supervision is needed. Staff will be trained on Section 87466 requirements
	8 9 10 11 12 13 14	record review showing that R1 experienced 12 falls.the presistent frequency and escalation in injury demonstrated inadequate development and implantation of supervision to meet R’1s needs. This possess an immediate health and safety risk to resident in care	8 9 10 11 12 13 14	Proof of the completed reviews and staff training will be submitted to LPA by the POC due date.

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 Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2026

LIC9099 (FAS) - (06/04)

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