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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336427244
Report Date: 05/30/2023
Date Signed: 05/30/2023 03:32:36 PM

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
05/23/2023 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230523095508
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:
05/30/2023
UNANNOUNCEDTIME BEGAN:
12:41 PM
MET WITH:Adella Tolentino, CaregiverTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Residents were confined in bed by staff as a form of restraint
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 residents and staff, and reviewed records.

It was alleged that five out of six resident's were laying in bed with bedrails up and legs elevated as a possible form of restraint. And further, residents allegedly were not helped in getting out of bed very often, though they would like to. Interview with residents revealed that those who were able to communicate, stated that they do, in fact, get out of bed by staff, and are not confined.

Continued on LIC9099C.
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: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
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 4
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
05/23/2023 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230523095508

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: DATE:
05/30/2023
UNANNOUNCEDTIME BEGAN:
12:41 PM
MET WITH:Adella Tolentino, CaregiverTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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9
Staff are unable to communicate with residents about their care needs
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 residents and staff, and reviewed records.

It was alleged that staff were not able to understand each resident’s care needs due to staff speaking a language not familiar to most residents. Through interview with residents, and staff, LPA determined that staff can speak a language that residents understand, and residents are able to have their needs met by staff through the communication exchange. Thus, this allegation was deemed to be 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.

This is an amended version of the original report dated 5/30/2023.
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: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20230523095508
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: 05/30/2023
NARRATIVE
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LPA observed Resident's in Room #1, Room #2, and one resident in Room #3 all had their bed not raised. Resident One (R1), who was in Room #4. R1's bed was elevated at the feet and when questioned, R1 advised that it was due to personal preference.

However, Resident Two (R2) in Room #3 was noted to have a cardboard box wedged between the frame at the foot, and the foot of the bed was partially raised. Staff interview revealed that this was done to keep R2 from getting out of bed, or rolling out of bed. LPA also noted that both of R2's bed rails were up extending the length of the bed. The facility was cited per Title 22, and thus, this complaint 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.

An exit interview was conducted where a copy of this report was 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: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20230523095508
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: 05/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/31/2023
Section Cited
CCR
87608(a)(1)
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Postural Supports: (a) Based on the individual's preadmission appraisal, and subsequent changes..provide assistance and care for the resident in those activities... Postural supports may be used under the following conditions.
(1) Postural supports.. spring release trays..to improve a resident's mobility.. functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc. This requirement was not being met as evidenced by:
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Licensee agrees to develop a plan to provide supervision for R1 and further agrees to conduct in-service training on personal rights and cited regulation, and provide proof of training by POC date.
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Based on staff interview and LPA observation, R1 had a box wedged between the bed and frame preventing R1 was exiting the bed. This poses an immediate personal rights risk to residents in care.
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CCR
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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: 08/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4