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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881094
Report Date: 05/17/2023
Date Signed: 05/17/2023 12:42:04 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/14/2022 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220114133222
FACILITY NAME:A SILVER AMORE SENIOR HOMEFACILITY NUMBER:
331881094
ADMINISTRATOR:DAS, IPSHITAFACILITY TYPE:
740
ADDRESS:12697 BURBANK ROADTELEPHONE:
(310) 985-2314
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:6CENSUS: 4DATE:
05/17/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ipshita Das, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility failed to provide adequate food service
INVESTIGATION FINDINGS:
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This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to conclude this agency’s investigation into the complaint allegations mentioned above. Upon arrival on this date LPA was met at the door by Caregiver Gariuna Key and granted entry. LPA is informed that she is here with four (4) residents. During this visit LPA interviewed four (4) residents in the home and one former resident telephonically.During the course of the investigation LPA received records of resident (R1)from the facility which included Horizon Home Health concent forms, Physician's Report signed 09/16/2021, Identification and Emergency information form dated 09/20/21, Centrally Stored Medication Logs dated 08/10/2022 through 11/09/2022, residents admission agreement signed 09/20/2021. LPA reviewed the menus dated 09/5/2021 through01/15/2022.and checked the available food supply. LPA is informed that the licensee has generated the facility menues. In regard to the allegation that the facility failed to provide adequate food service investigation revealed that the current available food supply. During todays visit LPA observed that lettuce and one small watermelon are their only available fresh produce and lunch meal consisted of a frozen Salisbury steak meal, bread and icecream. Based on the available information obtained the facility appears not to meet the recommended dietary allowances of the Food and Nutrition Board of the National Research Council.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
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 2
Control Number 18-AS-20220114133222
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: A SILVER AMORE SENIOR HOME
FACILITY NUMBER: 331881094
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/25/2023
Section Cited
CCR
87555(a)
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The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council...The facility is nott meeting this requirement as evidenced by:
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Licensee agreed to seek dietician consultation to review the quality and quantity of foods being served to ensure that their meal service is meeting the recommended dietary allowances of the food and Nutrition Board of the National Research Council followed.
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 During todays visit LPA observed that lettuce and one small watermelon are their only available fresh producee available and lunch meal consisted of a frozen Salsbury steak meal, bread and icecream. The facility does is not meeting the recommended dietary allowances of the Food and Nutrition Board of the National Research Council.
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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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2