415600869-4-29-2022-14-AS-JMOS-CE4VKS-20220504163047

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600869
Report Date: 04/29/2022
Date Signed: 04/29/2022 11:33:28 AM

Substantiated

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
02/16/2022 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220216135656

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: 64	DATE:	04/29/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Director of Health Services, Glynis Marcantel		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Private caregiver was not associated to the facility while providing care to resident
Facility failed to report to Licensing as required

INVESTIGATION FINDINGS:

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On April 29, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Director of Health Services, Glynis Marcantel, and explained the purpose of the visit.

Regarding the allegation that a private caregiver was not associated to the facility while providing care to a resident (R1): The private caregiver has been working at the facility for about 3 months. Although, the private caregiver was fingerprint cleared to work at the facility, the facility failed to associate the private caregiver. According to the staff interviewed, it was acknowledged that the facility was not aware they have to associate staff who were hired privately.

Based on the information and documentation collected, the private caregiver was never associated to Silverado Senior Living-Belmont Hills. The preponderance of evidence standard has been met; therefore, this allegation is Substantiated. This violation results in a civil penalty of $100 per day x 10 days = $1,000

Regarding the allegation that the facility failed to report to Licensing as required, on February 13, 2022, a private caregiver allegedly kicked a resident (R1) while providing care to him/her. Belmont Police Department responded to the incident and a report was taken the same day. Licensing became aware of this incident on February 16, 2022, 3 days after the incident took place. According to Title 22 Regulations, 87211, Reporting Requirements, the facility is required to notify Licensing and the Local Ombudsman within 24 hours of any suspected physical abuse of an elder. (CONT. TO 9099C).

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

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 6

Control Number 14-AS-20220216135656

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SILVERADO SENIOR LIVING - BELMONT HILLS	FACILITY NUMBER: 415600869
	VISIT DATE: 04/29/2022

NARRATIVE

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In addition, the facility is required to send Licensing a written report within seven days of the occurrence of any of the events indicated in Title 22 Regulation 87211(a)(1), (A) through (D). During the investigation, LPA was not given any proof of the facility reporting the incident between R1 and the private caregiver as required. Nevertheless, the facility failed to notify Licensing with 24 hours of the elder abuse and failed to provide Licensing a written report of the incident within 7 days.

Based on the information collected, it was determined that the facility failed to report to Licensing as required. The preponderance of evidence standard has been met; therefore, the above allegation is determined to be Substantiated.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 9099D. Failure to correct the deficiencies may result in civil penalties.

Report was reviewed with Director of Health Services, Glynis Marcantel and a copy is provided with appeals right.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 6

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
02/16/2022 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220216135656

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: 64	DATE:	04/29/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Director of Health Services, Glynis Marcantel		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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9

Physical Abuse - Private caregiver kicked resident

INVESTIGATION FINDINGS:

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On April 29, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Director of Health Services, Glynis Marcantel, and explained the purpose of the visit.

Regarding the allegation that a private caregiver (S1) kicked a resident (R1), during the investigation, the following was documented: The complainant reported that the resident (R1) slapped the private caregiver two times in the face, so the caregiver (C1) kicked him. During the investigation, LPA Charitra interviewed staff and reviewed R1’s documentation and file. Interviewed staff and file review indicated that R1 has dementia and has a history of aggression and volatile behavior. In addition, R1 has had several physical altercations with other staff members and residents. According to S1, on February 13, 2022, R1 slapped him/her two times on the face and appeared to be ready to slap him/her again. S1 indicated he/she was scared and “tapped” R1’s knees as self defense. R1 got startled and disengaged. Staff interviewed indicated that R1 has been becoming more volatile the past couple months.

Therefore, based on the file review, information collected, and interviews conducted, it is determined that the private caregiver reacted to defend herself/himself to the aggression of the resident; therefore the allegation is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.

Report was reviewed with Director of Health Services, Glynis Marcantel and a copy is provided with appeals right.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 6 of 6

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
02/16/2022 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220216135656

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: 64	DATE:	04/29/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Director of Health Services, Glynis Marcantel		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

1
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9

Unfingerprinted private caregiver was working with resident at the facility

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 14-AS-20220216135656

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SILVERADO SENIOR LIVING - BELMONT HILLS	FACILITY NUMBER: 415600869
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/29/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 04/30/2022 Section Cited CCR 87355(e)(2)	1 2 3 4 5 6 7	Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) Violation of this regulation is not met as evidence by:	1 2 3 4 5 6 7	Private caregiver no longer works at the facility. Facility will start associating all staff members moving foward, including privately hired caregivers and agency caregivers. Immediate civil penalty of $1,000 was issued today. $100 x 10 days = $1,000
	8 9 10 11 12 13 14	Based on record review and information collected, it was indicated that although the private caregiver was fingerprint cleared, the facility failed to associate the caregiver to the facility. In addition, the facility was unaware they had to associate staff who were hired privately.	8 9 10 11 12 13 14
Request Denied Type B 05/06/2022 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below… Violation of this regulation is not met as evidenced by:	1 2 3 4 5 6 7	Facility administrator to submit acknowledgement ot Title 22 Regulations for 87211(a), Reporting Requiements.
	8 9 10 11 12 13 14	Facility failed to report an incident that occurred on February 13, 2022 as required to Licensing. In addition, facility failed to submit a written report within 7 days of the occurrence date of the incident.	8 9 10 11 12 13 14

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: Julio Montes	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 14-AS-20220216135656

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SILVERADO SENIOR LIVING - BELMONT HILLS	FACILITY NUMBER: 415600869
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/29/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type B 05/06/2022 Section Cited CCR 87211(b)	1 2 3 4 5 6 7	87211 Reporting Requirements: (b) Any suspected physical abuse that results in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within two (2) hours as required by Welfare and Institutions Code Section 15630(b)(1). Violation of this regulation is not met as evidence by:	1 2 3 4 5 6 7	Facility administrator to submit acknowledgement ot Title 22 Regulations for 87211(b), Reporting Requiements.
	8 9 10 11 12 13 14	Facility failed to report an incident of alledged abuse that occurred on February 13, 2022 as required to Licensing. This poses a potential health and safety risk for 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: Julio Montes	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 6