415600869-12-18-2020-14-AS-KHOS-BX7QA8-20210112105931

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600869
Report Date: 12/18/2020
Date Signed: 12/18/2020 05:36:01 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
12/26/2019 and conducted by Evaluator Shabana Buksh

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20191226142809

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:	05:10 PM
MET WITH:	Joan Newman		TIME COMPLETED:	05:34 PM

ALLEGATION(S):

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Resident sustained injury due to lack of supervision

INVESTIGATION FINDINGS:

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On 12/18/2020, Licensed Program Analyst (LPA) Buksh, conducted an unannounced complaint investigation and met with the Administrator (name). The following allegation finding was discussed with the Administrator. The Department received complaint based on 2 incidents. Incidents dated 12/19/2019 and 12/21/2019. Regarding Incident dated 12/19/2019 involved residents, (R1 & R2). On 12/19/2020 around 11:25pm, NOC shift staff (S1) who had just started her shift heard somebody screaming. S1 tries to open the door the noise was coming from. The resident (R2) who stays in that room, opens the door and S1 found resident (R1) standing by the armoire. R1 alleged R2 of hitting her but no injuries were observed. This incident happened during the PM and NOC shift change. LPA interviewed 4 staff on this incident (2 NOC shift staff (S1 and S2) and 2 PM shift staff (S3 & S4) who were assigned to residents (R1 & R2) on 12/19/2019. All staff interviewed did not know how R1 wandered into R2's bedroom and how long she was in R2's room. Based on the interviews, it was determined that when NOC shift staff came to the floor, no (PM)staff were seen on the floor. Based on the review of the Work In/Out Report, both Staff in - charge of R1 and R2 clocked out at 11:32pm. The incident was witnessed at 11:29pm by NOC shift staff who starts shift at 11pm but arrived on the floor after endorsement (usually 30 mins). It was determined that PM shift staff were not on the floor and there were no supervision provided to residents at the time.
Findings for incident # 2 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)

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Control Number 14-AS-20191226142809

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)
Request Denied Type A 12/22/2020 Section Cited CCR 87468.2(a)(4)	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 agreed to develop a written plan of correction (POC) describing how facility shall ensure compliance with Regulation Title 22 - 87468.2(a)(4). Submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date. Failure to correct this deficiency by 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 meet the individual needs of residents, Staff was not present on the floor at the time of the incident to supervise (R1,R2,R3, &R4) which resulted in injuries, disturbance and posed an immediate Safety and Personal Rights risk to residents in care.	8 9 10 11 12 13 14	Immediate Civil Penalty of $500 was assessed for violation resulting in injuries occurred to a resident in care. 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)

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Control Number 14-AS-20191226142809

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..

Regarding Incident dated 12/21/2019 involving residents, (R3 & R4). On 12/21/2019 at 10:30pm , staff (S3) heard noises coming out from R3's bedroom. Upon checking, R3 was seen on the floor with Resident (R4) hitting her. R3 sustained bruises and cut to head. Based on the interview, LPA learnt that one of the staff went to use the restroom while the other staff was in the dinning room attending a resident. There was no other staff on the floor to monitor and supervise the residents. Staff stated that OAK neighborhood residents requires high level of care and usually 2 person assist is required. Staff stated that R4's behavior was discussed to their superior but no action was taken. Staff stated just recently there was a change in his medication but still requires lot of supervision.

R3's service plan dated 09/23/2019 to 1/28/2020 states the action taken by facility would be, "Resident will feel safe and respected" but on 12/21/2020, R4 was able to enter R3's room and physically assaulted R3 resulting in injuries. Staff did not have knowledge as how R1 and R4 wandered in R3 and R4's room while they were on duty providing care and supervision. On both the incidents, facility staff did not provide adequate supervision and Residents (R1,R2, R3, & R4) did not feel safe and respected which resulted in violation of residents' personal rights as stated in Residents' Admission Agreement.

The allegation is SUBSTANTIATED. The following deficiency was cited per CA Code of Regulations Title 22-refer to the 9099d. Immediate Civil Penalty of $500 was assessed for violation resulting in injuries occurred to a resident in care. Appeal rights served. 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)

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