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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336427244
Report Date: 05/17/2023
Date Signed: 05/17/2023 10:30:36 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/09/2023 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230509150545
FACILITY NAME:SILVER LIVING HOME CAREFACILITY NUMBER:
336427244
ADMINISTRATOR:CANDIDATO, FLORINAFACILITY TYPE:
740
ADDRESS:22590 TEMCO STTELEPHONE:
(951) 563-0181
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY:6CENSUS: 5DATE:
05/17/2023
UNANNOUNCEDTIME BEGAN:
08:31 AM
MET WITH:Adela Tolentino, CaregiverTIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Resident's needs are not being met
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to the facility to initiate a complaint investigation for the allegation listed above. LPA Gardner met with Caregiver Adela Tolentino and toured the facility. LPA informed staff of the purpose of the visit and the elements of the allegation. LPA conducted interviews with Resident One (R1) and staff.

It was alleged that R1 was refused assistance with toileting and staff refused to change R1's soiled diaper. Interview with confidential source indicated that the date on which this incident took place was approximately the week of May 1, 2023, R1 had not been changed in the morning.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
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 5
Control Number 18-AS-20230509150545
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SILVER LIVING HOME CARE
FACILITY NUMBER: 336427244
VISIT DATE: 05/17/2023
NARRATIVE
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Staff interviews indicated that it is protocol that each resident be changed before breakfast. Other staff interview revealed that if residents do not voice the need to be changed in the morning before breakfast, they do not check their diaper. Record review indicated that R1 is to be assisted with toileting. Thus, this allegation was Substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The facility was cited per Title 22.

An exit interview was conducted where a copy of this report was discussed and provided along with copies of the LIC9099D, and Appeal Rights.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
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)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/09/2023 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230509150545

FACILITY NAME:SILVER LIVING HOME CAREFACILITY NUMBER:
336427244
ADMINISTRATOR:CANDIDATO, FLORINAFACILITY TYPE:
740
ADDRESS:22590 TEMCO STTELEPHONE:
(951) 563-0181
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY:6CENSUS: 5DATE:
05/17/2023
UNANNOUNCEDTIME BEGAN:
08:31 AM
MET WITH:Adela Tolentino, CaregiverTIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Resident's personal rights are being violated
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to the facility to initiate a complaint investigation for the allegation listed above. LPA Gardner met with Caregiver Adela Tolentino and toured the facility. LPA informed staff of the purpose of the visit and the elements of the allegation(s). LPA conducted interviews with Resident One (R1) and staff.

It was alleged that R1 complained about toileting assistance the staff refused to help them, took away their snacks, and refused to provide them with 3 meals and gave them 2 meals a day, and took away their tv time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
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: 4 of 5
Control Number 18-AS-20230509150545
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SILVER LIVING HOME CARE
FACILITY NUMBER: 336427244
VISIT DATE: 05/17/2023
NARRATIVE
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Interview with R1 indicated that R1 has staff help when they voice it. R1 further indicated that they receive 3 meals a day, and their TV is always on and in their control. Thus, this allegation was Unsubstantiated.

A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.


An exit interview was conducted where a copy of this report was discussed with and provided.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
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)
Page: 5 of 5
Control Number 18-AS-20230509150545
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SILVER LIVING HOME CARE
FACILITY NUMBER: 336427244
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2023
Section Cited
CCR
87625(b)(3)
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Managed Incontinence (b) In addition to Section 87611...licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by:
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Licensee agrees to conduct in-service training on the cited regulation, and provide proof of completion by POC date to LPA.
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Based on staff interview, LPA found that staff are to change resident's before breakfast and/or inquire if they need changing. This was not done for R1. This poses a potential personal rights risk for residents in care.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
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: 3 of 5