374603165-3-2-2022-08-AS-SJAB-CCQU2Z-20220321151247

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603165
Report Date: 03/02/2022
Date Signed: 03/02/2022 04:09:24 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/26/2019 and conducted by Evaluator Denise Powell

COMPLAINT CONTROL NUMBER: 08-AS-20191126163450

FACILITY NAME:	SILVERADO SENIOR LIVING - ENCINITAS		FACILITY NUMBER:	374603165
ADMINISTRATOR:	GONZALEZ, JEFF		FACILITY TYPE:	740
ADDRESS:	335 SAXONY RD		TELEPHONE:	(760) 753-1245
CITY:	ENCINITAS	STATE: CA	ZIP CODE:	92024
CAPACITY:	0	CENSUS: 0	DATE:	03/02/2022
		UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Administrator, Marivel Johnson		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Lack of supervision resulting in resident injury

INVESTIGATION FINDINGS:

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Licensing Program Manager (LPM) Denise Powell conducted a follow up complaint visit to deliver findings regarding the above allegation and to conclude the investigation. The facility was closed on 3/3/21 due to a change of ownership; therefore, findings were delivered virtually with Administrator Marivel Johnson who confirmed that she is authorized to act as a designated representative of the previous licensee. The investigation consisted of interviews with staff and outside sources and records review, including facility and medical records.
On 11/26/19, it was alleged that lack of staff supervision resulted in Resident R1 (See LIC 811 Confidential Names list for disclosure) incurring an injury after an unwitnessed fall incident that occured on 10/28/19. R1 was found on the floor and sent out for medical evaluation. R1 returned to the facility the next day, on 10/29/19 and no further treatment was required. Review of records determined that R1 was ambulatory with the use of an assistive device, and had a history of prior minor falls at the facility, without injury. Interviews and observations noted R1 often did not use the assistive device to ambulate, despite staff reminders. Records showed R1 would also attempt to get up without staff assistance. R1's level of cognitive impairment was identified as an ongoing challenge to provision of care to meet resident's needs. (continued on next page)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Icela Estrada	TELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Denise Powell	TELEPHONE: 619-301-9770
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

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 08-AS-20191126163450

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SILVERADO SENIOR LIVING - ENCINITAS	FACILITY NUMBER: 374603165
	VISIT DATE: 03/02/2022

NARRATIVE

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Review of records determined that the facility had implemented additional fall preventive measures (high/low bed, fall mat, tab alarm) which were documented in R1's agreed-upon needs and services plan. Staff had discussed fall concerns and resident resistance to interventions during a care planning teleconference that was held with R1's responsible party, less than a week prior to the fall incident on 10/28/19. Staff expressed concern that R1 was removing the tab alarm at night and continued to try and get up without waiting for assistance. Interviews with staff and records confirmed that the facility followed required procedures to document ongoing observations of this resident, and consulted with R1's primary care physician and R1's responsible party to discuss this resident's increased care needs. On the day of the fall incident, staff had observed R1 in a common area approximately fifteen to twenty minutes before the resident was found on the floor of their their own room. Staff interviews and records showed R1 was being monitored at intervals consistent with the needs and services plan that was in place and with the current level of care assessment. Interviews with outside sources did not express having concerns about staff neglect or lack of supervision.

Evidence obtained during the investigation did not support the allegation that staff lack of supervision resulted in R1's injury. Based on interviews and record reviews, the allegation was determined to be unsubstantiated, meaning that although the allegation could have happened, there was insufficient evidence to prove the allegation occurred, and the preponderance of evidence standard was not met. An exit interview was virtually conducted with Administrator Johnson and a copy of this report provided via email, with electronic signatures and read receipt as confirmation of report delivery.

SUPERVISOR'S NAME: Icela Estrada	TELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Denise Powell	TELEPHONE: 619-301-9770
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

LIC9099 (FAS) - (06/04)

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