415600869-11-12-2021-14-AS-CSMH-CLAQLS-20221118111626

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600869
Report Date: 11/12/2021
Date Signed: 11/12/2021 02:08:55 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/14/2021 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210714115037

FACILITY NAME:	SILVERADO SENIOR LIVING - BELMONT HILLS		FACILITY NUMBER:	415600869
ADMINISTRATOR:	JOAN D NEWMAN		FACILITY TYPE:	740
ADDRESS:	1301 RALSTON AVE		TELEPHONE:	(650) 654-9700
CITY:	BELMONT	STATE: CA	ZIP CODE:	94002
CAPACITY:	112	CENSUS: 69	DATE:	11/12/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Glynis Marcantel		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident sustained unexplained injuries while in care

INVESTIGATION FINDINGS:

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On this day at 1100hrs Licensing Program Analysts (LPA) Jaime Vado and Komal Charitra conducted an unannounced visit to deliver findings on the allegation received. LPAs met with resident serviced direct Glynnis regarding the findings.

During course of the investigation LPA discovered that the resident was discovered with the unexplained injury at the same time as another staff person. Resident had an injury and was in bed. Resdient observation rounds were being made and in between rounds a fall may have ocurred and was assisted to bed by another resident. Staff do not help residents during a fall unless assisted by a nurse. Facility reported the fall to the regional office and the injury was diagnosed at the hospital.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021

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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