374604254-7-24-2023-08-AS-DPOL-CU6RR4-20230728131430

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604254
Report Date: 07/24/2023
Date Signed: 07/24/2023 03:23:07 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
07/18/2023 and conducted by Evaluator Carmen Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20230718114734

FACILITY NAME:	SILVERADO SENIOR LIVING-ENCINITAS		FACILITY NUMBER:	374604254
ADMINISTRATOR:	JOHNSON, MARIVEL		FACILITY TYPE:	740
ADDRESS:	335 SAXONY ROAD		TELEPHONE:	(949) 240-7200
CITY:	ENCINITAS	STATE: CA	ZIP CODE:	92024
CAPACITY:	122	CENSUS: 80	DATE:	07/24/2023
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Marivel Johnson, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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- Staff violated residents personal rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to open a complaint investigation. While at the facility LPA investigated and delivered findings regarding the above-mentioned allegation. LPA identified herself and was granted entry by Rhea Espinoza, Receptionist. LPA stated the purpose of the visit and reviewed the findings of the complaint with Marivel Johnson, Administrator.

The Department’s investigation consisted of interviews with staff and records review of relevant documents pertinent to this investigation. On July 17, 2023, it was alleged that facility staff violated residents’ personal rights.

It was specifically alleged that facility staff groomed hair from two residents peri/groin area without consent. Interview with the Administrator confirmed that the Facility conducted an internal investigation where they found staff #1 and staff #2 admitted to grooming three residents without the consent of their responsible parties. Upon the Facility’s discovery of the occurrence, they conducted their internal action for staff that included training.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

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-20230718114734

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SILVERADO SENIOR LIVING-ENCINITAS	FACILITY NUMBER: 374604254
	VISIT DATE: 07/24/2023

NARRATIVE

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A review of records revealed that the facility had self-reported the incident on an Unusual Incident/Injury Report to the Department on July 10, 2023. The report specified that the facility underwent an internal investigation regarding the incident which confirmed that there were not two, but three residents whose peri/groin area had been groomed. There were no injuries reported within the report.

Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff and outside source interviews, and records reviewed, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099D.

The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Administrator Marivel Johnson. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Administrator Johnson at the conclusion of the visit. The signature below confirms the receipt of these documents.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20230718114734

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SILVERADO SENIOR LIVING-ENCINITAS	FACILITY NUMBER: 374604254
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/24/2023 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a)(1) To be accorded dignity in their personal relationships with staff, residents, and other persons … this requirement was not met as evidence by:	1 2 3 4 5 6 7	The facility took internal action towards staff and conducted staff training. Internal action and training documents were provided to LPA during the visit.
	8 9 10 11 12 13 14	Based on interviews and records, staff did not protect the personal rights of the residents in care. This posed a potential personal rights risk to 3 [R1, R2, and R3] of 80 residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC9099 (FAS) - (06/04)

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