331881094-5-17-2023-18-AS-NBRN-CSLVRP-20230608164010

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881094
Report Date: 05/17/2023
Date Signed: 05/17/2023 12:41:06 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, 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 HOME		FACILITY NUMBER:	331881094
ADMINISTRATOR:	DAS, IPSHITA		FACILITY TYPE:	740
ADDRESS:	12697 BURBANK ROAD		TELEPHONE:	(310) 985-2314
CITY:	EASTVALE	STATE: CA	ZIP CODE:	92880
CAPACITY:	6	CENSUS: 4	DATE:	05/17/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Gariuna Key, Caregiver Ipshita Das, Administrator		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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Insufficient staffing to meet residents' needs
Facility failed to meet resident's showering needs
Staff failed to refill resident’s medication in a timely manner
Facility failed to issue a refund

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 reviewed five (5) resident records. 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 08/10/2021 through 11/09/2021, and admission agreement signed 09/20/2021. LPA reviewed the menus dated 09/5/2021 through 01/15/2022 and checked the available food supply. LPA reviewed staffing schedules.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (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)

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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
	VISIT DATE: 05/17/2023

NARRATIVE

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Investigation revealed the following information: It is alleged that there are not enough staff to meet the residents needs. Review of five (5) resident records did not reveal any direct supervision order or two person lift orders. LPA review of staffing schedules show varying staffing from one (1) to two (2) staff on a 24 hour basis. There is no available information to indicate that staffing is insufficient in relation to supervision or care needs. It is alleged that the staff failed to meet R1's showering needs. Interview with R1 revealed that they did not have any issues in regard to the staff meeting their showering needs.
It is alleged that staff failed to refill R1's medication. Interview with R1 did not reveal any information that would support the allegation. Review of R1's centrally stored medication records did not reveal any apparent information to indicate medication errors. It is alleged that the facility failed to issue a refund. Interview with the Licensees indicate that a refund was issued in order to prorate the monthly rent. R1 was refunded $387.09 dollars on 01/31/2022 for the last week of December 2021. R1 indicated that they were not expecting a refund. Based on the information available we have found the complaint allegations are unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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