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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603165
Report Date: 10/14/2022
Date Signed: 10/14/2022 03:48:11 PM

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
09/21/2020 and conducted by Evaluator Daniel Pena
COMPLAINT CONTROL NUMBER: 08-AS-20200921115126
FACILITY NAME:SILVERADO SENIOR LIVING - ENCINITASFACILITY NUMBER:
374603165
ADMINISTRATOR:JOHNSON, MARIVELFACILITY TYPE:
740
ADDRESS:335 SAXONY RDTELEPHONE:
(760) 753-1245
CITY:ENCINITASSTATE: CAZIP CODE:
92024
CAPACITY:0CENSUS: 0DATE:
10/14/2022
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Mailed Certified Via USPSTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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-Facility neglect resulted in the questionable death of a resident in care
-Facility did not ensure adequate staffing to meet resident needs
-Facility neglected to update a resident’s care plan after multiple falls
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.

This complaint consisted of the following allegations: facility neglect resulted in the questionable death of a resident in care; facility failed to ensure adequate staffing to meet resident needs and facility neglected to update a resident’s care plan after multiple falls.

On 9/21/2020, the San Diego Adult and Senior Care Program received a complaint regarding the aforementioned allegations. The Department’s investigation consisted of facility visits, resident and outside source record reviews, and interviews with staff and Resident 1’s (R1) responsible person.

On 9/9/2020, at about 7:15 PM, R1 had an unwitnessed fall. Staff observed R1 laying on the carpeted
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
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 3
Control Number 08-AS-20200921115126
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: 10/14/2022
NARRATIVE
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floor in a common area. Staff assessed R1 and determined their vitals were within normal range. Staff noted a raised bump on the back upper left side of R1’s head. R1 complained of pain. 911 was activated and R1 was transported to the hospital for medical care.

Medical records showed R1 arrived at a local hospital emergency department by ambulance on
9/9/2020 at 9:26 PM with the chief complaint: “Fall.” Records indicated R1’s visit diagnoses were Subdural hematoma (primary); bleeding in brain; contusion of scalp without laceration and Alzheimer’s dementia without behavioral disturbance. R1 was transferred to another hospital on 9/10/2020 to provide R1’s responsible person time to decide the level of care and intervention needed for R1. R1’s responsible person declined surgery for R1 and directed that R1 return to the facility under hospice care. R1 passed away at the facility on 9/16/2020.

R1’s Certificate of Death documented the immediate cause of death as “Blunt Force Injury of Head.”
Other significant conditions contributing to R1’s death but not noted as the underlying cause were “Dementia and Hypertensive Cardiovascular Disease.” Records and interviews did not provide evidence to indicate that the facility could have prevented R1’s fall or provided neglectful care.

An outside source also alleged that the facility failed to ensure adequate staffing to meet resident’s needs. Interviews of the staff working on the night of R1’s fall were completed as part of this investigation. On the evening of R1’s 9/9/2020 fall, Staff 1 (S1) was in the common area with approximately 4-5 residents, including R1. S1 last noticed R1 sitting on a recliner chair in the corner of the room. S1 was assisting another resident in the front of the room when they heard a noise that sounded like something hitting the floor. S1 did not visually witness the fall but turned around and saw R1 on the floor. R1 was lying on their back next to the recliner chair. S1 called out to Staff 2 (S2) for assistance who responded. Additionally, Staff 3 (S3), a licensed vocational nurse, arrived and assessed R1. R1 was noted to have a nodule on the back of their head. 911 was activated and R1 was transported to the hospital for medical care. Interviews revealed that generally speaking, staff checked R1 and other residents at least every two hours to monitor and assist as needed for safety. Interviews also related that the facility does not provide 1-on-1 resident care.

In regard to the allegation that the facility failed to update R1’s care plan due to multiple falls, interviews and records characterized R1 as very mobile and active. Since moving into the facility, R1 experienced seven witnessed and unwitnessed falls, including the 9/9/2020 incident. None of the first six falls resulted in
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20200921115126
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: 10/14/2022
NARRATIVE
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serious injuries or hospitalization.

Interviews with staff queried if R1’s care plan should have been updated prior to R1’s 9/9/2020 unwitnessed fall. Staff advised that R1 liked to walk and move around the facility. R1 did not like anyone touching them and refused assistance from staff. Staff stated R1 was free to walk/move about the facility and staff could not prevent them from walking. R1 also did not need or use assistive devices. Records reflect that the facility did develop a care plan to address R1’s fall history which included monitoring devices (tabs alarm, pressure alarm) in R1’s room and on R1’s bed. R1 was given “hip savers” (padding on hip) as a precaution for falls. Generally speaking, staff checked R1, as with other residents, every two hours to monitor and assist as needed for safety.

The Department has investigated the allegations that the facility neglected resident which resulted in the resident’s questionable death; failed to ensure adequate staffing to meet resident needs and neglected to update a resident’s care plan after multiple falls. Based on the information reviewed 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 they 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 JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3