415600869-12-18-2020-14-AS-KHOS-BXGJL4-20210121060805

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600869
Report Date: 12/18/2020
Date Signed: 12/18/2020 05:59:56 PM

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
01/13/2020 and conducted by Evaluator Shabana Buksh

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200113132917

FACILITY NAME:	SILVERADO SENIOR LIVING - BELMONT HILLS		FACILITY NUMBER:	415600869
ADMINISTRATOR:	HOLLAND, CHERESE		FACILITY TYPE:	740
ADDRESS:	1301 RALSTON AVE		TELEPHONE:	(650) 654-9700
CITY:	BELMONT	STATE: CA	ZIP CODE:	94002
CAPACITY:	112	CENSUS: 89	DATE:	12/18/2020
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Joan Newman		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff failed to provide adequate care and supervision to resident resulting in death.

INVESTIGATION FINDINGS:

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On 12/18/2020, Licensing Program Analyst (LPA) Buksh, conducted a video tele - complaint investigation with Administrator, Joan Newman. LPA was given a virtual video tour of the facility by the administrator. LPA visually inspected the physical condition of the facility and health and safety of the residents’ present. LPA discussed the following findings of the above allegation with the Administrator.
On 01/13/2020, the Department received a complaint alleging that Facility failed to provide adequate care and supervision to a resident resulting in death. The initial facility investigation was conducted on 01/15/2020. The department’s investigation of this complaint includes review of resident’s medical records, facility and other miscellaneous records, statements and interviews with staff and other possible witnesses.
The Department’s finding for the above allegation is as follows; Resident (R1) was admitted and arrived at the facility on 01/08/2020 at 2:49PM. Despite documentation in his care plan, physician’s report (Dated 01/06/2020), prior facilities progress notes and several adamant warnings of aggressive and combative behavior from R1’s responsible party, prior to admission, Silverado assured they had adequately trained staff who would be able to handle R1’s behaviors. Instead, Silverado failed to fully assess R1 and provided a 1:1 caregiver(S1) who was apprised with minimal information on R1 and his behaviors and was not well trained to provide care and supervise to meet R1’s needs.

Continues on next page LIC 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Shabana Buksh	TELEPHONE: (650) 266-8810
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2020

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 14-AS-20200113132917

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: 12/18/2020

NARRATIVE

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Narrative Continued..

Resident (R1)'s first day at the facility, according to facility progress notes, R1 was observed with agitation, combative behavior and hitting staff. The same behaviors were observed on the second day (incident day).Silverado Staff admitted that it required several caregivers to assist the 1:1 staff (S1) with changing R1 and their job was also to assist the 1:1 staff providing care and supervisor to R1. Multiple staff at Silverado reported that the 1:1 staff kept her distance from R1 on multiple occasions due to R1’s combative behavior. The 1:1 staff admitted that she would close R1’s room door and sit outside. When questioned why she sat outside of R1’s room leaving him unsupervised, S1 said, “Because he will hit me!”

On the day of the incident, when S1 went inside R1’s room to check on him, R1 was able to kick the door open and leave the room, walking into other resident’s room. When S1 tried to re - direct R1 back to his room, S1 stated that R1 attempted to punch her. S1 started to walk fast down the hallway and as she was doing so, R1 said, “run for your life!” S1 said, she yelled out for help as she was “running” down the hallway. In addition, staff stood by and watched R1 “chase” S1 several hundred feet down the hallway and ignored S1’s pleas for help. Further, it was reported by staff that during the nocturnal (NOC) shift, caregivers were frequently caring for 20- 30 residents at a time and did not have help due to being short staffed. Because of R1’s diagnosis that causes lean when R1 walks (from R1’s Appraisal report, conducted by Silverado on 1/5/2020). R1 tripped while chasing staff, resulting in him falling forward onto the floor. Immediate assessment revealed abrasions to right cheek, right temporal area, right eyelid directly below the brow ridge, right side of chin and right upper lip with a scant amount of blood coming from mouth. Abrasions were also noted on bilateral knees. Resident exhibited seizure like shaking and became unresponsive. 911 was called and R1 was sent to the ER. At 17:45 on the same day, resident passed away due to blunt force injuries of head and arms complicating stroke as a result of the fall.
The allegation is SUBSTANTIATED.

The deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Section 8 and is noted on attached LIC 9099-D. Immediate Civil Penalty of $500 was assessed for violation resulting in death due to injuries occurred to a resident in care. The licensee was informed that a civil penalty is pending review and shall be assessed based on Health and Safety Code 1569.49(e). Appeal rights served.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Shabana Buksh	TELEPHONE: (650) 266-8810
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 14-AS-20200113132917

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: 12/18/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 12/22/2020 Section Cited CCR 87468.2(a)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.	1 2 3 4 5 6 7	Administrator stated, will develop a written plan of correction (POC) in writing describing how facility shallensure compliance with Regulation Title 22 -87468.2(a)(4) and shall describe facility plan how similar incident related to violation will be prevented in the future for health and safety of residents. POC shall be received in licensing office by fax and/or mail by due date. Failure to meet POC due date may result in a civil penalty of $100 or more per day.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews and record reviews, Licensee failed to deliver care, supervision and services that met the individual need of resident(R1), which resulted in R1's fall while chasing his 1:1 staff and resulted in R1's death due to the injuries occurred. This posed an immediate Health, Safety and Personal Rights risk to residents in care. See LIC 9099 for detailed findings.	8 9 10 11 12 13 14	Immediate Civil Penalty of $500 was assessed for violation resulting in death due to injuries occurred to a resident in care. The licensee was informed that a civil penalty is pending review and shall be assessed based on Health and Safety Code 1569.49(e). Appeal rights served.
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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: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Shabana Buksh	TELEPHONE: (650) 266-8810
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 3