SILVERADO SENIOR LIVING - CALABASAS

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes...appropriate assistance is provided when such observation reveals unmet needs... physician and the resident's responsible person, if any This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as staff noted R1 had changes in their skin beginning on 04/20, but did not have home health until 05/24, R1's family member was not made aware until 05/31/23, which posed an immediate health risk to R1

Official plan of correction

Administrator agreed to submit to CCL current policies and procedures related to observation of the resident, reporting, and prohibited health conditions. Administrator will document current process for reporting change of condition and communication. Documentation will be sent to CCL by POC due date.

Deadline recorded: Sep 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

87615(a)(1) Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained... (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as R1 had documented stage 3 pressure injuries as well as total ADL care and R1 was not admitted to hospice care at that time, which posed an immediate health risk to persons in care.

Official plan of correction

Administrator agreed to submit to CCL current policies and procedures related to observation of the resident, reporting, and prohibited health conditions. Administrator will document current process for reporting change of condition and communication. Documentation will be sent to CCL by POC due date.

Deadline recorded: Sep 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services (f) (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking...Postural Supports This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section as S1 did not transfer R1 per R1's care plan, which resulted in R1 falling, sustaining injury, and R1 passed away as a result, which posed an immediate health and safety risk to persons in care.

Official plan of correction

Administrator stated Hoyer lift training was completed immediately following the incident, and additional vendored training was also provided. Disciplinary action involving S1 has been completed. Administrator provided documentation of trainings and disciplinary action completed, POC cleared.

Deadline recorded: Mar 26, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation during medication review, the licensee did not comply with the section cited above as counts for 2 (two) of R1's medications do not match and the documentation does not reflect the discrepancy, which poses a potential health risk to persons in care.

Official plan of correction

POC Due Date: 03/27/2025 Plan of Correction Administrator agreed to review medication procedures with all staff who administer medications. Administrator will ensure completion of the training and will provide a copy of the training materials and attendee roster to LPA by POC due date.

Official classification

Type B

Official code

1569.312(a)

Regulation authority

HSC

What the official deficiency says

1569.312(a) Basic services requirements. Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Facility staff neglected to supervise R1 during meals, which posed a potential health and safety risk to residents in care.

Official plan of correction

Administartor will submit a plan how they will ensure appropriate care and supervision to meet the needs of residents. Submit to CCL by 1/10/2025.

Deadline recorded: Jan 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87217(b)

Regulation authority

CCR

What the official deficiency says

87217 (b) Safeguards for …Personal Property, and Valuables. Every facility shall... safeguard residents'... personal property and valuables which have been entrusted...The licensee shall give the residents receipts for all... This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as personal items of R1 went missing while in care, which posed a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Administrator will submit a plan to properly safeguard residents' property as well as provide staff training regarding safeguarding residents' personal property. Submit to CCL by POC date.

Deadline recorded: Jan 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

87705(f)(1) Care of Persons with Dementia. (f) The following shall be stored inaccessible... Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as razors were observed accessible in Room 53, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. Secured the items upon observation. POC is cleared at this time.

Deadline recorded: Aug 1, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(g)(1)

Regulation authority

CCR

What the official deficiency says

87705(g)(1) Care of Persons with Dementia. … Residents with dementia shall be allowed to keep personal grooming and hygiene items … unless there is evidence to substantiate that the resident cannot safely manage the items. This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply in the section cited above for one out of three residents (R1), which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to the following: 1. Secure the items by the end of the day. Inform CCL when this has taken place 2. Conduct an in-service training with care staff, regarding items that shall be inaccessible to residents with dementia. Submit sign-in sheet no later than 8/11/2023. Submit POC to CCLASCPWoodlandHillRO@dss.ca.gov, ATTN: Officer of the Day

Deadline recorded: Aug 1, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464(f)(1) Basic Services. Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interview and records review, the licensee did not comply with the section cited above, as the facility failed to ensure that R4 did not leave the facility unassisted per the physician report, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator has agreed to do the following: 1. The facility has also reviewed and held an in-service training regarding Elopement procedures. Plan of Correction met.

Deadline recorded: Aug 2, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(d)(3)

Regulation authority

CCR

What the official deficiency says

87465(d)(3) Incidental Medical and Dental Care. The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by: Based on medication review, the licensee did not comply in the section cited above for 2 out of 3 (R2, R3) residents as it pertains to documentation for assisting residents with the self-administration of PRN medication, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator has agreed to do the following: 1. Host an in-service training, discussing topics that include but are not limited to: PRN documentation, checking centrally stored forms for accuracy. In-service must include nurses and medication technicians. Submit initial sign-in sheet by 8/2/2023. Training for all must be completed by 8/11/2023

Deadline recorded: Aug 2, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

87411(f) Personnel Requirements – General. … Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician .... This requirement is not met as evidenced by: Based on file review, the licensee did not comply to the section cited above for three out of five staff (S1, S2, S3), which poses a potential health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. Obtain the completed health screenings and/or TB results for S1, S2 and S3. Submit proof by 5/31/2023

Deadline recorded: May 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87355(d)

Regulation authority

CCR

What the official deficiency says

87355(d) Criminal Record Clearance. All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury. This requirement is not met as evidenced by: Based on file review, the licensee did not comply to the section cited above for two out of five staff (S1, S2), which poses a potential health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. Obtain the completed criminal record statements for S1 and S2. Submit proof by 5/31/2023

Deadline recorded: May 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident. When changes … are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person… This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above, as staff did communicate changes to hospice staff in a timely manner, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1.Submit a Plan of Action/Protocol, detailing how nursing staff are expected to communicate with outside collateral agencies. Submit protocol to CCLD by 11/18/2022. 2. Review this protocol with nursing staff within the next two weeks. Submit proof of completion to CCLD, but no later than 11/29/2022

Deadline recorded: Nov 18, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

87464(f)(4) Basic Services. Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident … with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications. This requirement is not met as evidenced by: This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above, as staff were unable to meet R1’s care needs on multiple occasions, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator has agreed to do the following: 1. Submit a Plan of Action/Protocol, detailing how staff are trained to meet care needs of those that may exhibit aggressive behaviors. Submit protocol to CCLD by 11/18/2022. 2. Schedule an in-service training for caregivers and LVNs that specifically speaks to this protocol. Training needs to be completed in the next two weeks. Submit proof of completion to CCLD, but no later than 11/29/2022

Deadline recorded: Nov 18, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(d)(3)

Regulation authority

CCR

What the official deficiency says

87465(d)(3) Incidental Medical and Dental Care. The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by: Based on medication review, the licensee did not comply in the section cited above for three out of five (R1, R2, R3) residents as it pertains to documentation for assisting residents with the self-administration of PRN medication, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator has agreed to do the following: 1. Host an in-service training, discussing topics that include but are not limited to: PRN documentation, checking centrally stored forms for accuracy, ensuring DC orders are in, medication changes. In-service must include nurses and medication technicians. Submit initial sign-in sheet by 11/04/2022. Training for all must be completed by 11/10/2022.

Deadline recorded: Nov 4, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411(a) Personnel Records. The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement is not met as evidenced by: Based on record review, the licensee did not comply in the section cited above for four out of ten staff (S2, S3, S6, S7), which poses a potential health and safety risk to residents in care.

Official plan of correction

The Administrator has agreed to do the following: 1. Obtain the missing items. Inform the Department when this has taken place, but no later than 6/10/2022

Deadline recorded: Jun 10, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

87411(f) Personnel Requirements - General. (f) Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. This requirement is not met as evidenced by: Based on record review, the licensee did not comply in the section cited above as for four staff (S1, S6, S7, S8) need a health screening and three staff (S1, S3, S8) need TB results, which poses a potential health and safety risk to residents in care.

Official plan of correction

The Administrator has agreed to do the following: 1. Obtain the missing items. Inform the Department when this has taken place, but no later than 6/10/2022

Deadline recorded: Jun 10, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411(f) Personnel Requirements - General. (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Based on record review, the licensee did not comply in the section cited above in three out of ten staff (S2, S3, S7) need TB results, which poses a potential health and safety risk to residents in care.

Official plan of correction

The Administrator has agreed to do the following: 1. Obtain the missing items. Inform the Department when this has taken place, but no later than 6/10/2022

Deadline recorded: Jun 10, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355(e)(1) Criminal Record Clearance. (e) All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department... This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply in the section cited above for two staff (S1, S2), which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to the following: 1. The two identified staff will not work in the community until appropriate clearance is obtained. Staff will submit a Statement of Understanding, confirming this action, no later than 6/2/2022.

Deadline recorded: Jun 2, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

87464(f)(4) Basic Services. Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing... This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above as R1's hygiene needs were not met, which poses a potential health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. Submit a Plan of Action, indicating how the facility will maintain compliance with ensuring that residents are regularly observed and hygiene needs are met for all residents. Submit the Plan of Action to CCL no later than 4/22/2022.

Deadline recorded: Apr 22, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211(a)(1)(D) Reporting Requirements. A written report shall be submitted to the licensing agency... within seven days of the occurrence of any of the events...: (D) Any incident which threatens the welfare, safety or health of any resident .... This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as the presence of a rash on five residents was not reported to CCL in February 2021, which posed a potential health and safety risk to persons in care.

Official plan of correction

The Licensee agreed to do the following: 1. Submit incident reports for the five residents by the POC due date.

Deadline recorded: Feb 11, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following...: 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. This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as staff failed to provide proper care to R1 after administering insulin, resulting in R1 becoming hospitalized, which poses an immediate health and safety risk to residents in care.

Official plan of correction

No additional POC will be required at this time, as the facility submitted a comprehensive plan on what steps would be taken to ensure residents’ needs were met. Original POC was due 2/1/2019 and cleared 2/4/2019 An immediate civil penalty of $500 will be assessed. As this is a repeat violation, an additional civil penalty of $1,000 will be assessed today.

Deadline recorded: Nov 29, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following...: 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. This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as R1 and R2 suffered falls while in care which resulted in serious injuries, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: Submit a Plan of Action, documenting how the facility identifies whether a resident is a fall risk and the subsequent supports put in place to best assist resident needs. Submit plan by 12/1/2021. Review protocol with nursing staff. Submit proof that staff have reviewed protocol no later than 12/6/2021 Repeat citation; immediate civil penalty assessed.

Deadline recorded: Dec 1, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

87615(a)(1) Prohibited Health Conditions. Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained … (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on interview and records review, the licensee did not comply with the section cited above, as R1 was retained in the facility with a stage III pressure injury, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. Host an in-service training with care staff, regarding regulation 87615 Prohibited Health Conditions and 87631 Healing Wounds. Communicate scheduled date to the Department by 9/15/2021. Training must be completed within two weeks.

Deadline recorded: Sep 15, 2021. A deadline is not proof that correction was completed.