Silverado Senior Living-Berkeley

We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: Case Management - Health Checks

On 07/10/2026, at 10:45 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct a health and safety check as a result of a priority 2 complaint. The LPA informed Executive Director (ED) Morgan Whinery of the purpose of the visit. The LPA toured the interior and exterior of the facility, including but not limited to, clients’ rooms, bathrooms, kitchen, common areas, and the garden areas. The LPA observed adequate lighting for the comfort and safety of clients in all rooms. Inside and outside areas are free of obstruction and no bodies of water. The temperature in the lobby area was measured at 75 degrees Fahrenheit and the maximum hot water temperature in Resident's room was measured at 113 degrees Fahrenheit. There is more than the minimum of a one-week supply of nonperishable foods and 2 days of perishable foods. The fire extinguishers were fully charged and last serviced on 05/14/2026. The medications were stored in a locked medication cart. First aid kit was observed to be complete. No citations were issued during the inspection. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 10, 2026

Allegation investigated: Staff did not safeguard residents personal property Staff did not ensure resident was changed/cleaned properly

On 06/17/2026 at 9:20 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to deliver the findings on the above allegations. LPA met with Administrator, Morgan Whinery and explained the purpose of the visit. During the course of investigation, LPA interviewed 7 Staff, 10 residents, and 6 witnesses. LPA obtained and reviewed documents including but not limited to the resident roster, staff roster, admission agreement, resident personal property and valuables, resident identification and emergency information, unusual incident/injury report (LIC624), police information, facility's investigation report, caregiver agency contact information, staff contact information, and progress notes. Continue to LIC9099-C... Unsubstantiated Continued from LIC9099... Allegation: Staff did not safeguard residents personal property It was alleged that staff did not safeguard residents personal property. Interview with W1 and W2 both revealed that the facility did not do an inventory list with a R1. However, interviews with S1 and S2 disclosed that during the time of admission, family members of R1 and R2 refused to sign the Client/ Resident Personal Property and Valuables (LIC621) form. Interview with W4 revealed that when R3 moved to the facility, W4 had to drop off R3’s belongings to the front desk and the facility will take inventory and label all R3’s belongings. Interview with 5 of 7 residents all stated that they have not observed any of their belongings missing or misplaced while staying in the facility. S1 stated that per W1 and W2, R1 and R2 had their rings when they first arrived at the facility. Photos obtained on the visit conducted on 4/21/26 showed that on 2/5/26, R1 and R2 did not have their rings on. S1 stated the staff members usually take photos and videos of residents when they first arrive to show family members how residents adapt to their community with the family consent. Interview with W6 indicated that R1 and R2’s 1:1 caregiver provided by the facility took photos of R1 and R2 that showed both residents did not have jewelry on when they first moved into the facility. Based on interviews and record reviews conducted, the above allegation that staff did not safeguard residents personal property is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff did not ensure resident was changed/cleaned properly It was alleged that staff did not ensure resident was changed/cleaned properly. Interview with W1 and W2 indicated that there was an incident that occurred that left a resident without underwear and the resident ended up defecating in their pants. Continue to LIC9099-C... Continued from LIC9099-C... Interviews with S1 and S3 both stated that when a resident first moves into the facility, residents are provided with a 1:1 caregiver service from an outside agency for 72 hours so that the residents can be closely monitored. Interview with S4 stated that there was an incident that occurred where R1 had a bowel movement while walking. S4 stated that S4 and the 1:1 caregiver from the outside agency assisted R1 with a shower after the incident occured. S4 also confirmed that R1 was wearing a diaper during that time. Interview with S1 and S4 indicated that there was no documentation of the incident that happened with R1. Interview with R8, R9, and R10 indicated that staff members will assist residents with going to the bathroom or diaper changes. Interview with W5 stated that they visit R10 daily and observe staff checking in on R10 multiple times throughout the visit to assist with R10’s needs. Based on interviews conducted, the above allegation that staff did not ensure resident was changed/cleaned properly is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited. Exit interview conducted and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Jun 17, 2026 · control 15-AS-20260311092131

Allegation investigated: Staff did not follow the reporting requirements Resident was not able to go on an outing due to staffing issues

On 5/4/26 at around 9 am, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct an investigation of the above allegations and to deliver findings for the above allegations. LPA explained the purpose of the visit to the Executive Director (ED), Morgan Whinery. Allegation: Staff did not follow the reporting requirements: Unsubstantiated During the course of the investigation, the Licensing Program Analyst (LPA) reviewed resident files and interviewed eight (8) residents, the Executive Director (ED), and three (3) staff members. The allegation stated that staff failed to follow required reporting procedures. However, interviews with the ED and staff, along with documentation reviewed, including but not limited to the Unusual Incident Report (UIR) and confirmation of fax transmission to Community Care Licensing Division (CCLD), as well as the Administrator Daily Operation Sheet dated 04/21/2026, indicate that the facility did complete the required reporting. Report contiuned on LIC 9099c... Unsubstantiated Report continued LIC 9099c... Records show that the incident involving Resident 1 (R1) occurred on 04/18/2026. Documentation confirms that the facility submitted the UIR to CCLD via fax on 04/26/2026 at approximately 3:25 p.m. The Administrator Daily Operation Sheet further indicates that on 04/21/2026, the ED discussed the incident with O1, provided the UIR to O1. Allegation: Resident was not able to go on an outing due to staffing issues: Unsubstantiated During the course of the investigation, the Licensing Program Analyst (LPA) interviewed eight (8) residents, the Executive Director (ED), and three (3) staff members. The allegation indicated that a resident was unable to participate in outings due to insufficient staffing. However, interviews with the ED and staff, as well as documentation reviewed, including but not limited to the facility’s planned activities calendar and LPA observations, do not support this claim. Resident 1 (R1) reported, “I can go on outings, but during the time that is scheduled, I don’t want to go and only want to go with S2.” This statement indicates that R1’s lack of participation in outings is based on personal preference rather than staffing limitations. Additionally, other residents and staff did not report any concerns about being unable to attend outings due to staffing shortages. Based on the information obtained through interviews, record review, and observation, there is insufficient evidence to support the allegation that staffing issues prevented the residents from going on outings. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove them; therefore, the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided via email.the state’s words, verbatim · CDSS document, May 4, 2026 · control 15-AS-20260427163254

Type of visit: Case Management - Other

On 5/4/26, LPA K. Nguyen conducted case management based on files reviewed, which showed that the incident for R1 occurred on 4/18/26 and was reported on 4/26/26, within the 7-day requirement during a complaint visit (15-AS-20260427163254). The interview showed that R1 was not admitted to the hospital due to R1's refusal; however, the facility has an on-site nurse who conducted an evaluation after the fall and noted that there was no serious injury at the time of the fall. LPA requested that Ed review 87211 Reporting Requirements and submitted a self-certified letter of understanding regarding the regulation mentioned above, including protocol of facility reporting requirement and submit to CCLD by the POC date of 5/8/26. No citation issue on today's date. Exit interview conducted and a copy of this report provided via email.the state’s words, verbatim · CDSS document, May 4, 2026

Type of visit: Required - 1 Year

On 04/21/2026 at 11:30 AM, Licensing Program Analysts (LPAs) K. Nguyen and P. Manalo conducted an unannounced required 1 Year inspection. LPAs met with Morgan Whinery, Administrator, and explained the purpose of the visit. LPA toured the facility with ADM, who's currently holding a certificate (7022660740) that expires on 09/17/2026. The facility’s fire clearance was approved for ninety (90) non-ambulatory residents; sixty-two (62) may be bedridden. LPAs and ADM toured the facility, including, but not limited to, bathrooms, shower rooms, common areas, the medication room/nursing station, the laundry room, dining areas, and the courtyard. A comfortable temperature of 72 degrees Fahrenheit (F) was maintained. LPAs observed that lighting in all areas was adequate for the residents' comfort and safety. Hot water temperature in the shared residents' bathroom was measured at 109, 110, 112, 112.9, 110, and 115 degrees Fahrenheit. Linen and hygiene products were available for all residents. There is a minimum of one week supply of nonperishable and 2-day perishables food supply. Carbon monoxide were in operating condition during visit. Fire Alarm Annual Inspection was last conducted on 12/05/2025. Fire extinguishers was last serviced on 05/13/2025. Emergency Disaster Drill was last conducted on 03/14/2026. First aid kit was observed to be complete. Seven (7) staff records were reviewed, and 7 of 7 staff are associated with the facility. Seven (7) residents records were reviewed. LPAs reviewed samples of client's medications. ...continued on LIC9099C. ...continued from LIC9099. Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 04/28/2026: LIC 500 Personnel Report LIC 308 Designation of Administrative Responsibility Liability Insurance THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: At 10:50 AM, LPAs observed moldy strawberries in the kitchen walk-in fridge. At 11:01 AM, LPAs observed ointments found in the bathroom connecting rooms #3 and #4, ointments in the shared shower room, Flonase in room 202 upstairs, and A&D ointment in room #222. At 11:10 AM, LPAs observed a pocket knife and a staple remover in room #27, Lysol wipes inside the rabbit cage on the second floor, and multiple razors in room #222. At 11:12 AM, LPAs observed a resident's drawer broken, the medication room with a hole in the wall, and multiple bathroom vents not working properly. At 11:33 AM, LPAs observed the side emergency exit door blocked with multiple items such as foldable tables, a vacuum, a whiteboard, and other debris. At 3:07 PM, record review revealed that 7 of 7 staff members don't have CPR certification on file. The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code. Failure to correct deficiencies by POC date may result in Civil Penalties. Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 21, 2026

We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: Case Management - Deficiencies

On 04/07/2026 at 2:00PM, Licensing Program Analysts (LPAs) T Syess-Gibson and L. Hall conducted a case management as a result of information received during complaint visit 15-AS-20260401130802. LPAs met with Morgan Whinery, Administrator, and explained the purpose of the visit. While conducting the complaint investigation LPAs was informed by S1 that the incident report for R1's hospitalization was not submitted to CCLD within seven days of the occurrence. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, a copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 7, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Apr 16, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age..This requirement is not met as evidence by: Based on interview and record review the Licensee did not comply with the section cited above in reporting R1’s incidents to CCLD, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 7, 2026

Plan of correction: By POC date, Administrator agreed to submit R1's incident report for hospitialization to CCLD.

Type of visit: Case Management - Incident

On 10/16/2025 at 1:00 PM, Licensing Program Analysts (LPAs) Y. Brown and A. Gomez conducted a case management visit as a result of a self-reported incident report received 10/10/2025. LPA met with the Administrator Michelle Neumann. It was reported that R1 was found after an unwitnessed fall. LPAs reviewed R1's care plan, physicians report and toured the facility. R1 returned back to the community and was re-accessed for any changes in condition. LPAs reviewed a random sample of staff records and found that all their training's were up to date. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 16, 2025

Allegation investigated: Staff did not provide adequate supervision resulting in resident being sexually assaulted.

On 09/09/25 around 12:15 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the complaint findings. LPA met with Michelle Neumann, Senior Administrator Specialist and explained the purpose of the visit. During the course of investigation, the Department obtained copies of the following documents: Records for Residents (R1, R2, R3, R4) including, but not limited to the most recent Physician's Reports, 02/10/25 to 03/10/25 Progress and Care Notes, facility's incident form dated 03/10/25. Centrally Stored Medication and Destruction Records/Medication Lists, Service Detail Plans, Admission Agreements, ID/Emergency Contact information/Face Sheets. LPA requested a staff and resident roster. The Berkeley Fire Department (BFD), and Berkeley Police Department (BPD) were involved in the investigation; a police report was obtained by the Department for R1’s medical records from Highland Hospital Alameda Medical Center in Oakland, California which also contained R1’s Sexual Assault Response Team (SART) report. Continued on LIC9099C... Unsubstantiated ...continued from LIC9099. In addition, statements were obtained from Staff (S1, S2, S3, S4, S5, S6) and Witnesses (W1, W2, W3, W4, W5). The allegation occurred on 03/10/25 around 06:48 AM. S5 assisted R1 with ADL’s, charted details of bruises on R1’s body and reported the incident to S1. S1 stated that he/she had never seen any bruises like this before on R1’s body and contacted 911. BFD arrived on site at the facility. BFD obtained urines samples, reported R1’s physical and mental condition BPD. On 03/10/25 at 06:50 PM, BPD responded to BFD personnel; W1 was present to assist with R1’s language translation. It was alleged that staff (W2) sexually assaulted R1. Due to R1’s diagnosis of Dementia, R1 was not able to provide details or additional information about the bruises and R1’s statements did not consist of sexual assault. W2 denied sexually assaulting R1 and stated that he/she had not observed any bruising or had any sexual contact with R1. W2’s last contact with R1 was through W2’s shift on 03/09/25 that ended around 10:45 PM. W2 was not employed by the facility, instead by R1’s family. On 03/09/25 at 05:40 PM, S5 and S6 provided care to R1 with ADL’s and toileting. S6 did not observe anything unusual or bruising on R1. S7 stated and reported on R1’s Progress notes dated 03/10/25 at 07:57 AM that R1 slept for 4.5 hours and noted R1 using his/her hands to hit his/her legs; it was very loud, and the noise was heard at the nursing station in the next room #28, R1 resided in room #29. PRN Codeine and Olanzapine were given to R1 at 3:09 AM, noted effective, and no abnormal findings were reported by W2. Records and interviews from S1, S2, S3, W1, W2, and W3 revealed that R1 was a fall risk, there was no evidence of sexual assault and no determination for the cause of bruises on R1. Based on all the information obtained, there was not enough evidence to conclude that R1 was sexually assaulted; therefore, the allegation is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and copy of this report provided to Michelle Neumann, Senior Administrator Specialist.the state’s words, verbatim · CDSS document, Sep 9, 2025 · control 15-AS-20250320151634

Type of visit: Case Management - Health Checks

On 03/21/25 around 11:00 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a 10-day complaint investigation and a Health and Safety inspection. LPA met with Administrator (ADM) Jeffrey Emoruwa and explained the purpose of the visit. LPA toured facility including, but not limited to the shared bathroom, common area, outdoor and indoor areas; indoor and outdoor passages were free of obstruction. Hot water temperature in the shared restroom was measured at 110.4 degrees F. Resident's are housed in individual apartment style rooms with adequate lighting in each room for the safety of residents. Resident rooms were observed to be clean and fully furnished. Facility purchases food 2-3 times a week to maintain 7-days of non-perishables, and 2-days of perishable foods. Resident's medications are kept locked in a medication cart located in the medication room on the 1st and 2nd floor. Smoke and Carbon monoxide detectors observed operational. Fire extinguisher was observed to be full and last serviced on 05/14/2024. There are no accessible bodies of water observed. No deficiencies cited during visit. Exit interview conducted and a copy of this report was provided to Jeffrey Emoruwa, Administrator.the state’s words, verbatim · CDSS document, Mar 21, 2025

Type of visit: Case Management - Incident

On 03/21/25 around 01:15 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a case management for an infectious outbreak. LPA met with Administrator (ADM) Jeffrey Emoruwa, and explained the purpose of the visit. On 03/12/25, S1 informed LPA that fifteen (15) residents were manifesting gastrointestinal (GI) symptoms that included diarrhea, and vomiting. To date, the facility has closed communal dining. All residents are on Bananas, Rice, Applesauce, and Toast (BRAT) diet, and are offered clear fluids every 2 hours. Visitors and staff has been informed to wear PPE while caring for these residents and to wash their hands with soap and water regularly. Local Public Health (PH) department provided advisories to be posted at the main entrance to advise all incoming visitors and staff. PPE is available at the entrance, sufficient and recommended for all. Environmental services inspected kitchen and negative of any infectious disease. PH estimates that Tuesday, 03/25/25, all should be clear at the facility. A copy of this report provided to the Jeffrey Emoruwa, Administratorthe state’s words, verbatim · CDSS document, Mar 21, 2025

Type of visit: Case Management - Incident

On 03/05/25 around 10:00 AM L. Holmes, Licensing Program Analyst (LPA) arrived unannounced to conduct a case management regarding two (2) Unusual Incident Reports (UIRs). LPA was greeted by the Receptionist and explained the purpose of the visit while Jeffrey Emoruwa, Administrator (ADM) attended a meeting. ADM arrived about ten (10) minutes later. On 02/21/25, LPA received an email from ADM reporting 2 staff made physical contact with 2 residents on 2 different occasions. The facility became aware of the incidents evening on 02/19/25, and the investigation is still in progress. Staff (S1, S2) were suspended on 02/19/25 pending the results of the investigation; residents involved were (R1, R2). S4 alleged that S1 made contact to R1's left cheek while trying to stop R1 from be being agitated, throwing glass and trying to hit at S1. S4 stated that the incident happened in the dining area about a month ago (01/2025) S3 alleged that S2 slapped R2's forearm in an effort to prevent R2 from placing his/her hands inside their own briefs. S3 stated that the incident occurred about 2 months ago (12/2024) in R2's bedroom. Human Resources conducted a one (1) day investigation on site, and 1 day of calling for interviews; four (4) additional caregivers and 2 nurses were assigned to the facility to assist. W1 interviewed ADM also. S1 resigned prior to completion of the investigation. At this time, the facility's investigation is inconclusive. Exit interview conducted and a copy of this report provided to Jeffrey Emoruwa, Administrator.the state’s words, verbatim · CDSS document, Mar 5, 2025

Type of visit: Required - 1 Year

On 03/05/2025 around 12:00 PM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced Required 1 Year inspection. LPA met with Jeffrey Emoruwa, Administrator and explained the purpose of the visit. LPA toured the facility with ADM who currently holds a certificate (#7016762740) that expires on 08/05/26. The facility’s fire clearance was approved for ninety (90) non-ambulatory residents; sixty-two (62) may be bedridden. Upon arrival LPA observed two (2) staff attending to the residents that were interacting and congregating in the common area of the facility. LPA, ADM and S5 toured the facility including, but not limited to bathrooms, shower room, common areas, medication room/nursing station, laundry room, dining areas and courtyard. The facility consists of individual apartments style rooms housed by the residents. Residents were exercising, playing the piano and listening to music. All outdoor and indoor passageways were free of obstruction. There were not any bodies of water. A comfortable temperature was maintained at 72 degrees Fahrenheit (F). LPA observed lighting in all areas to be adequate for the comfort and safety of the residents. Hot water temperature in the shared residents' bathroom was measured at 113 degrees (F). All toilets, hand washing, and bathing areas were safe, sanitary and in operating condition. Hand washing signs, paper towels, and soap observed at all hand washing stations. Linen and hygiene products were available for all residents. PPE, sanitizer, and paper goods remain sufficient. ...continued on LIC9099C. ...continued from LIC9099. The facility is masking per City of Berkeley's Public Health recommendations. Smoke detectors and carbon monoxide units were in operating condition during visit. Fire extinguishers were observed full and last inspected 05/13/2024. Emergency Disaster Plan is updated. Safety drill was conducted last quarter by Safety First. Five (5) staff records were reviewed, and all staff have criminal record clearances. Seven (7) residents records were reviewed and are complete. The following forms are to be updated and submitted to CCLD: -Resident Roster -LIC500 Personnel Report -LIC308 Designation of Administrative Responsibility (Reviewed) -LIC610 Emergency Disaster Plan (Reviewed) -An updated copy of Administrator Certificate(s) (Reviewed) -Liability Insurance No deficiencies cited during visit. Exit interview conducted and a copy of this report provided to Jeffrey Emoruwa, Administratorthe state’s words, verbatim · CDSS document, Mar 5, 2025

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 10/08/24 around 01:45 PM L. Holmes, Licensing Program Analyst (LPA) arrived unannounced to conduct a case management regarding reporting requirements. LPA met with Durga Acharya, Receptionist and explained the purpose of the visit while Jeffrey Emoruwa, Administrator (ADM) attended a meeting. On 09/13/24,LPA L. Holmes received an email from LPA L. Sampair with COVID-19 report and death reports that were provided to licensing from the facility. Five (5) of the ten (10) reports sent by Silverado Berkeley were late and did not meet the regulatory guidelines for notifications and reporting. LPA requested that ADM advise CCLD when the facility has been cleared of COVID-19 so that a case management could be conducted for late reporting of the deaths and incidents that had occurred during the month of August. On 09/16/24, ADM advised that the facility did not have any COVID-19 cases and essentially the facility was clear. ADM stated that he’d speak with their Director of Health Services to find out more about the late reporting. Based on information obtained the deficiency is cited from Title 22 California Code of Regulations and listed on LIC 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights, and copy of this report provided to Durga Acharya, Receptionist .the state’s words, verbatim · CDSS document, Oct 8, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 15, 2024

Reporting Requirements. A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified... This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not submitting incident reports to CCLD within seven days which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Oct 8, 2024

Plan of correction: ADM agreed to conduct in-service staff retraining on reporting in a timely manner and submit to CCLD completed certifications as proof of correction.

Type of visit: Required - 1 Year

On 4/19/2024 at 9:20AM, Licensing Program Analysts (LPAs) G. Luk and L. Holmes arrived unannounced to conduct a Required - 1 Year inspection. LPAs met with Administrator, Jeffrey Emoruwa and explained the purpose of the visit. The facility’s fire clearance was approved for 90 non-ambulatory residents of which 62 may be bedridden and 20 residents may be under hospice care. LPAs toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, common areas, and outdoor area. Centrally stored medications were locked in medication cart. First Aid kit is complete. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detectors were observed. Fire extinguisher was observed to be full and last serviced on 5/2/2023. One week supply of nonperishable and 2-day supply of perishable foods were available. Facility purchase food supplies 2-3 times a week. Freezer’s temperature was registered at -2 degree F while the refrigerator’s temperature was recorded at 38 degrees F. Hot water temperature was measured at 106.5 degrees F in a resident's bathroom sink. Grab bars for each shower and toilet were installed. Non-skid mats were observed. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. Indoor and outdoor passages were free of obstruction. Last fire drill was conducted on 4/14/2024. LPAs reviewed 5 resident records and 5 staff records starting at 11:30AM. LPAs conducted interviews with 4 residents and 4 staff during inspection. LPAs also reviewed a sample of resident's medications and MAR (Medication Administration Record). At 12:24PM, LPAs observed residents (R1, R2, R3, R4, R5) does not have current medical assessments on file. (Continue on LIC809C...) At 1:30PM, LPAs observed S2, S3, and S4 does not have current First Aid training on file. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted with Jeffrey Emoruwa. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 19, 2024

Allegation investigated: Facility staff did not provide adequate supervision resulting in a resident eloping from the facility. Facility staff disclosed resident's personal information in the presence of others at the facility.

On this day at around 10:15 am,, Licensing Program Analyst (LPA Luisa Fontanilla arrived unannounced to deliver findings on the above allegations and met with Jeffrey Emoruwa. LPA explained to Emoruwa the purpose of the visit. On 1/30/2024, LPA initiated the 10-day investigation and interviewed Staff 1 (S1) and Staff 2 (S2) via zoom due to the facility’s covid outbreak status. Based on interviews conducted, both S1 and S2 confirmed with LPA that on 1/2/2024, Resident 1 (R1) wandered off the facility without staff knowledge. The alarm went off but the staff who responded to the door failed to see R1 exit the facility. R1 was observed outside the facility by one of the caregivers who finished the shift. R1 was brought back to the facility without any injury. R1 has Dementia and is not able to leave the facility unassisted. continuation on Lic 9099C Substantiated After the incident, R1’s wife requested a meeting with S1 and S2 together with two other individuals who are not related to R1 but have family members living at the facility. During the meeting, plans and procedures were discussed on how to make sure that R1 is safe while living at the facility. And part of the agenda was to discuss R1’s medications. Based on interviews conducted, S2 states that it was an oversight on the part of the facility to allow other individuals who are not involved in R1’s care to be part of the meeting since the purpose of the meeting is to address R1's condition and there is always a possibility of disclosing R1’s personal information. Based on interviews and records reviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are substantiated. California Code of Regulations, Title 22 are being cited on the attached Lic 9099D. Exit interview was conducted with Emoruwa and Appeal Rights was provided.the state’s words, verbatim · CDSS document, Apr 17, 2024 · control 15-AS-20240122165538

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.312 · Plan of correction due date: Apr 17, 2024

H&S §1569.312 (a) Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. -This requirement is not met as evidenced by: Based on interviews and record reviews conducted, R1 who has dementia and is unable to leave facility unassisted wandered off the facility without staff knowledge which poses a potential risk to the health and safety of clients under care. R1 was returned to the facility without any injury.the state’s words, verbatim · CDSS document, Apr 17, 2024

Plan of correction: The Administrator has conducted training with staff on 1/9/2024 and provided CCL proof of training. In addition, the Administrator states that actual head counts are being conducted 3x a day in addition to the head counts being conducted by individual caregivers. The Administrator will send additional health and safety plans to CCL to ensure health and safety of residents by 4/30/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(2) · Plan of correction due date: Apr 30, 2024

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: (2) To have their records and personal information remain confidential and to approve their release, except as authorized by law. This requirement is not met as evidenced by: Based on interviews conducted, R1’s medication information was disclosed during the meeting held with R1’s wife and 2 other individuals.the state’s words, verbatim · CDSS document, Apr 17, 2024

Plan of correction: The Administrator states have been advised not to disclose any information to anyone who is not directly responsible for the care of the resident.

Type of visit: Case Management - Incident

On 03/08/2024 at 11:30AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 2/26/2024. LPA met with Director of Health Services(DHS) and explained the purpose of the visit. The incident report received stated that Resident (R1) eloped from the south side exit door of the facility at 7:17PM on 02/24/24. Staff (DHS) reviewed security footage and confirmed R1 eloped at 7:17PM that night. Staff reset the exit door alarm at 7:19PM and did not immediately look for missing R1. Records review of R1's physician's report dated 06/24/22 indicated that R1 is not able to leave the facility unassisted. Incident report dated 02/26/24 showed that R1 was noted missing by staff at 7:30PM when caregiver went to look for R1 to assist him to bed. At 7:43PM, R1 was reportedly found by a concerned citizen who called the facility with the location of R1. Staff returned R1 safely back to the facility at 8PM on 02/24/24. DHS stated staff notified her of R1's elopement incident at 8:17PM on 02/24/24. LPA obtained a copy of the staff roster, resident roster, resident's (R1) physician's report and progress notes for the month of February 2024 during the visit. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of appeal rights and this report was provided to DHS.the state’s words, verbatim · CDSS document, Mar 8, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705 · Plan of correction due date: Mar 29, 2024

In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement was not met as evidenced by the lack of timely response by staff to actively find resident (R1) when he eloped from the facility’s south side exit security door on 02/24/24.the state’s words, verbatim · CDSS document, Mar 8, 2024

Plan of correction: By POC due date, DHS agreed to conduct in-service staff retraining on safety measures to timely implement proper resident elopement procedures in compliance with Title 22 Section 87705 Care of Persons with Dementia and submit to CCL completed staff retraining certifications as proof of correction.