415600869-2-16-2024-14-AS-KCHA-D2HPY5-20240216104322

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600869
Report Date: 02/16/2024
Date Signed: 02/16/2024 10:43:36 AM

Document Has Been Signed on 02/16/2024 10:43 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	SILVERADO SENIOR LIVING - BELMONT HILLS		FACILITY NUMBER:	415600869
ADMINISTRATOR:	ROBERT SNEE		FACILITY TYPE:	740
ADDRESS:	1301 RALSTON AVE		TELEPHONE:	(650) 654-9700
CITY:	BELMONT	STATE: CA	ZIP CODE:	94002
CAPACITY:	112	CENSUS: 72	DATE:	02/16/2024
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Administrator, Robert Snee		TIME COMPLETED:	11:00 AM

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On February 16, 2024, Licensing Program Analyst (LPA) Komal Charitra met with Administrator, Robert Snee and Director of Health Services, Amyda Astrero for a Case Management visit to follow up on a substantiated complaint allegation of neglect and lack of supervision resulting in serious bodily injuries.

On October 10, 2019, the Department concluded a complaint investigation which alleged that the facility did not provide proper care and supervision which resulted in a resident (R1) sustaining multiple falls including a serious bodily injury. The allegation was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87464(f) Basic Services.

The investigation revealed the facility failed to do an accurate fall risk assessment after R1 experienced multiple fall incidents at the facility on June 17, 2018, July 15, 2018, October 11, 2018, October 17, 2018, and December 19, 2018. As a result, the facility failed to identify and implement measures and or plan of care changes to minimize further fall incidents for R1. Based on documentation reviewed, according to the facility’s assessment, it was not identified that R1 was a high risk for falls.

On March 1, 2019, R1 had another unwitnessed fall and was hospitalized. Based on the investigation, it was revealed that there are three small buildings on this property. There were no caregivers present in R1’s building before or at the time R1 fell. Two caregivers were in another building and a licensed vocational nurse (LVN) was in a med room, but the LVN was not answering their phone. As a result of the improper risk assessment and facility’s failure to identify and implement a proper plan of care to address R1’s fall risk; R1 sustained a right intertrochanteric femur fracture and needed to undergo an operation called femur intramedullary rodding. (Continue to 809C)

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SILVERADO SENIOR LIVING - BELMONT HILLS	FACILITY NUMBER: 415600869
	VISIT DATE: 02/16/2024

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In addition, based on the documents and information collected, the investigation revealed that the facility was aware of R1’s multiple falls, but continued to provide care based on inaccurate fall risk assessments, outdated plan of care, and did not notify the Primary Care Physician (PCP) of the changes until R1’s fall on March 1, 2019. There was no facility report or documentation available for review to indicate facility staff or the administrator had notified the PCP about R1’s fall history or a plan of care necessary to minimize R1’s risk for falls.

At the time of the complaint visit on October 10, 2019, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty was being determined and might be assessed based on Health and Safety Code § 1569.49.

The Department has concluded an analysis and has determined that an additional civil penalty is warranted for a violation that resulted in R1 sustaining serious bodily injuries while under the care of this facility. Welfare and Institutions Code § 15610.67, defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility failing to provide the proper care and supervision to R1, knowing that R1 was a fall risk, resulting in R1 falling and sustaining a right intertrochanteric femur fracture, which is serious bodily injury.

Today, February 16, 2024, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as a serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on October 10, 2019, the amount of the civil penalty issued today will be $9500.

A copy of the LIC 421D was given to Administrator, Robert Snee and originals were signed.

Exit interview conducted. A copy of the report issued. Appeal rights provided. Administrator, Robert Snee signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

LIC809 (FAS) - (06/04)

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