415600869-2-25-2025-14-AS-ACON-DEF37Z-20250303170045

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600869
Report Date: 02/25/2025
Date Signed: 02/25/2025 02:06:13 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
12/27/2024 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20241227093734

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: 89	DATE:	02/25/2025
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Administrator, Robert Snee		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff did not seek timely medical attention for a resident

INVESTIGATION FINDINGS:

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On February 25, 2025, Licensing Program Analyst (LPA) Komal Charitra conuducted an unannounced complaint visit to deliver the finding for the above allegations. LPA met with Administrator, Robert Snee and explained the purpose of the visit.

Regarding the allegation, staff did not seek timely medical attention for resident, according to the reporting party, on 12/23/24, Resident 1 (R1) had a witnessed fall at 11am and the facility did not seek timely medical attention until 4:54pm when R1's responsible party told S1 to call 911 after calling for an update and being notified by Staff 1 (S1) that R1 is in severe pain and can't move his/her leg.

During the investigation, LPA interviewed administrator, staff, and reviewed documentation. Based interviews conducted, 3/3 staff members indicated R1 had a witnessed fall at 11am and complained of pain. Staff immediately responded, assisted R1 from the floor and assessed R1. S1 and Staff 2 (S2) indicated that they reached out the the doctor for advice, however the doctor was not responding. S1 and S2 checked on R1 throughout the day and R1 still complained of pain.

(Continue to 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 629-4305
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025

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 5

Control Number 14-AS-20241227093734

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SILVERADO SENIOR LIVING - BELMONT HILLS	FACILITY NUMBER: 415600869
	VISIT DATE: 02/25/2025

NARRATIVE

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S2 who was on the AM shift admitted that he/she should have called 911 immediately after resident had a fall and complained of pain, however indicated because resident was not in severe pain, S2 did not call 911. S1 who was on shift during the PM shift, indicated he/she was not sure why the facility did not send R1 to the hospital after the fall in the morning. The facility did not send R1 out to the hospital till about 5:30pm when R1 started moaning, complaining of pain, and couldn't move his/her legs. Based on medical records reviewed, due to the fall, R1 sustained a left hip fracture.

Based on the investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Failure to correct said deficiencies may result in additional civil penalties.

AN IMMEDIATE CIVIL PENALTY OF $500.00 WAS ASSESSED TODAY: $500 FOR THE VIOLATION AS STAFF DID NOT SEEK MEDICAL ATTENTION FOR A RESIDENT.

THE ADMINISTRATOR WAS INFORMED THAT AN ADDITIONAL CIVIL PENALTY IS STILL BEING DETERMINED AND MIGHT BE ASSESSED BASED ON HEALTH AND SAFETY CODE §1569.49.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 629-4305
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
12/27/2024 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20241227093734

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:	DATE:	02/25/2025
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Administrator, Robert Snee		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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9

Staff did not properly inform responsible party of care needed for resident

INVESTIGATION FINDINGS:

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On February 25, 2025, Licensing Program Analyst (LPA) Komal Charitra conuducted an unannounced complaint visit to deliver the finding for the above allegations. LPA met with Administrator, Robert Snee and explained the purpose of the visit.

Regarding the allegation, staff did not properly inform responsible party of care needed for resident, according to the reporting party, on 12/23/24, Resident 1 (R1) had a witnessed fall at around 11am, and the facility did not notify R1's responsible party till around 2:50pm. In addition, reporting party indicated that R1's responsible party contacted the facility at around 4:54pm regarding an update on R1's condition because the facility did not contact R1's responsible party after the initial call at around 2:50pm.

During the investigation, LPA interviewed administrator, staff and reviewed care notes. According to the administrator and staff interviewed, R1 had a fall at 11am during the Staff 2 (S2) was on shift. According to S2, he/she called R1's responsible party at 1:30pm. (Continue to 9099C)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 629-4305
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025

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 5

Control Number 14-AS-20241227093734

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SILVERADO SENIOR LIVING - BELMONT HILLS	FACILITY NUMBER: 415600869
	VISIT DATE: 02/25/2025

NARRATIVE

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According to the administrator and the Director of Health Services, the facility's protocol is to have the shift nurse call responsible parties regarding incidents that occur before they leave their shift. The facility did notify R1's responsible party based on interview conducted with S2, administrator and Director of Health Services. Based on care notes reviewed, it was observed that S2 did contact R1's responsible party.

Based on the above information, the Department has found that this allegation to be UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis.

Report is reviewed with the administrator and a copy is provided.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 629-4305
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 14-AS-20241227093734

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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: 02/25/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/26/2025 Section Cited CCR 87465(a)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care - (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/administrator shall submit a plan in writing addressing how to seek timely medical attention.
	8 9 10 11 12 13 14	Licensee failed to seek timely medical attention after R1 had a fall and complained of pain. Based on interviews and records reviewed, R1 had a fall at 11am and R1 was not sent out to the hospital till about 5:30pm. Based on interview conducted with S2, S2 admitted that 911 should have been called immediately after R1 had a fall and complained of pain, however indicated because resident was not in severe pain, S2 did not call 911. Nevertheless, R1 complained to 3 staff members of pain and observed by staff of having pain and the facility did not seek medical attention for R1 which poses an immediate health risks to residents in care and resulted into a left hip fracture.	8 9 10 11 12 13 14	Civil penalty in the amount of $500.00 is being assessed today as the facility failed to seek timely medical treatment for Resident 1 (R1) after an incident that occurred on 12/23/24 which resulted in a fractured left hip.
	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: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 629-4305
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 5