374603165-10-13-2022-08-AS-IESA-CKR7QM-20221031215210

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603165
Report Date: 10/13/2022
Date Signed: 10/13/2022 11:05:15 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
07/23/2020 and conducted by Evaluator Daniel Pena

COMPLAINT CONTROL NUMBER: 08-AS-20200723104617

FACILITY NAME:	SILVERADO SENIOR LIVING - ENCINITAS		FACILITY NUMBER:	374603165
ADMINISTRATOR:	JOHNSON, MARIVEL		FACILITY TYPE:	740
ADDRESS:	335 SAXONY RD		TELEPHONE:	(760) 753-1245
CITY:	ENCINITAS	STATE: CA	ZIP CODE:	92024
CAPACITY:	0	CENSUS: 0	DATE:	10/13/2022
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Mailed Certified via USPS		TIME COMPLETED:	11:10 AM

ALLEGATION(S):

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-Facility neglect resulted in the questionable death of a resident in care
-Facility neglect, resulted in unexplained weight loss for a resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Daniel Pena completed an investigation regarding the aforementioned complaint allegations. Since the facility closed on 3-3-2021 due to a change in ownership, the allegation findings were delivered to the licensee via USPS certified mail.

It was alleged that facility neglect, resulted in unexplained weight loss for a resident in care. It was also alleged that facility neglect resulted in the questionable death of a resident in care.

On 07/22/2020, the San Diego Adult and Senior Care Program received a complaint regarding the aforementioned allegations. The Department’s investigation consisted of facility and collateral site visits, facility and outside source record reviews, and interviews with staff, Resident 1’s (R1) responsible person and outside sources.

The complaint alleged that the facility failed to seek medical attention in a timely manner which may have

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

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-20200723104617

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SILVERADO SENIOR LIVING - ENCINITAS	FACILITY NUMBER: 374603165
	VISIT DATE: 10/13/2022

NARRATIVE

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contributed to R1’s death. Records reflect that R1 was admitted into Silverado on 3/5/2020. A Physician’s Report, dated 2/18/2020, showed R1’s primary diagnosis as Alzheimer’s and secondary diagnoses to include hypertension, hyperlipidemia, and osteopenia. R1 was non-verbal, non-ambulatory and able to feed themselves. Records described R1’s health status as “fair.”

Outside sources could not cite any particular failures by the facility to provide care to R1 but felt they should have had R1 seen by a primary care physician sooner. Records noted that R1’s responsible person was designated as Power of Attorney and decision maker for R1’s medical care. Interviews with staff and R1’s relatives consistently confirmed that the facility made numerous attempts to contact R1’s physician in response to R1’s refusal to eat and worsening dementia.

The complaint contended that R1 lost 40 pounds from 5/11 to 5/26/2020. The last facility recorded weight entry for R1 on 5/11/2020 was 183.8 pounds. On 5/26/2020, R1’s weight was taken and recorded at the hospital at 149 pounds. As to the cause of R1’s weight loss, medical provider records showed that R1 was diagnosed with end-stage dementia, a clinical history of altered mental status and failure to thrive. R1’s records showed that the facility made efforts to address R1’s refusal to eat. Records show that the facility gave R1 a supplemental protein shake and tried cutting R1’s food into small pieces but R1 would still not cooperate. Interviews reported that as R1’s dementia progressed R1 ate less and less. R1’s responsible person ultimately directed that R1 be transported to the hospital for evaluation and treatment since attempted calls to R1’s physician were not returned.

On 5/27/2020, R1 was discharged from Silverado, transported to the hospital and then transferred to a hospice care provider. Records again reflected that prior to transfer; R1 refused to eat, take medications, displayed agitation, and refused to follow directions. R1’s physical exam records taken on 5/26/2020, showed that R1 appeared well-developed, well-nourished but distressed. On 6/2/2020, R1 passed away at the hospice care provider.

The Death Certificate showed the immediate cause of R1’s death as cardiorespiratory disease and Alzheimer’s. No notes or documentation found in R1’s records showed evidence or concerns of neglectful care by Silverado.

The Department has investigated the allegations that facility neglect resulted in unexplained weight loss

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20200723104617

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SILVERADO SENIOR LIVING - ENCINITAS	FACILITY NUMBER: 374603165
	VISIT DATE: 10/13/2022

NARRATIVE

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and questionable death of a resident in care. Based on the information obtained during the course of this investigation, insufficient evidence was obtained to support the allegations. Therefore, the findings are determined to be Unsubstantiated. Although the allegations may have occurred or could be valid, there is not a preponderance of evidence to prove it occurred.

A copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were mailed to licensee via USPS certified mail.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

LIC9099 (FAS) - (06/04)

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