Silverado Senior Living-Beverly Place

Type of visit: Required - 1 Year

On May 8, 2026, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Assistant Director of Health Services Maria D Roldan and Regional Director of Operations Taylor Guinto. LPA Dabuet explained the purpose of today’s visit. The facility is licensed to operate for (256) non-ambulatory elderly adults of which (92) may be bedridden ages 60 and above. Currently, the facility has (109) residents and (16) in hospice care. The facility is approved for (36) hospice residents. The facility is a three-story structure located in a residential neighborhood. It consists of the following: (114) residents' rooms, (114) bathrooms (12) guest restrooms, a lobby, a theater, a gym, a library, a beauty salon, a dining area, a kitchen, a spa, a bistro, (3) wellness rooms, a game room, outside courtyards, and a parking garage. LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. The residents’ rooms were inspected 109, 114, 145, 206, 230, 247, 307, 310, 334, 264, 342, and the gym. Bathrooms were operational with water temperature measured at 105.9 – 112.0 degrees F. A comfortable temperature was maintained in the facility at 73 - 76 degrees F. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Evaluation Report continues LIC 809-C Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable in each resident's room. The facility has conducted Fire and Disaster Drill March 13, 2026. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted including activities and food menu calendars. LPA conducted an audit of resident #1-#7 (R1-R7) service files, and staff #1-#7 (S1-S7) personnel files were in order and complete. The facility is current in CCLD annual fees. The facility has a current administrator certificate for Stephanie Brynojolfson #6011996740 valid through July 7, 2026. The facility has a current liability insurance policy #SCP-143177739-02 from July 01, 2025 through July 1, 2026. No deficiencies were found during this inspection. An exit interview conducted with Taylor Guinto, and a copy of the report is provided.the state’s words, verbatim · CDSS document, May 8, 2026

Allegation investigated: Staff did not adequately supervise resident in care resulting in resident eloping from the facility. Staff did not adequately supervise resident in care resulting in resident sustaining injuries.

***This amended report supersedes the report dated January 26, 2026 and February 12, 2026. This report has been created to include detailed description of "Staff did not adequately supervise resident in care resulting in resident sustaining injuries". All other aspects of the complaint report remain in effect. *** This unannounced subsequent complaint investigation visit is being conducted by the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet for the purpose of delivering findings for the investigation into the above identified complaint allegations. Stephanie Brynjolfson Executive Director greeted the LPA and explained that the purpose of the visit. The investigation included interviews, record reviews, and a tour of the facility. Interviews with Staff member S#1 - S#6 (S1-S6) and Resident #2 - #10 (R2- R10). (Evaluation Report continues LIC 9099-C) Substantiated The Department reviewed several documents, including the Facility Resident Roster (dated 01/22/26), the Personnel Report LIC 500 (dated 01/21/26), (R1's) Physician’s Report LIC 602A (dated 9/11/26), the Preplacement Appraisal Information LIC 603 (dated 09/10/25), Unusual Incident Report LIC 624 (dated 01/24/26), Facility Surveillance Camera Footage (dated 01/18/26), and other pertinent records associated with this complaint. Allegation #1: Staff did not adequately supervise resident in care resulting in resident eloping from the facility. Allegation #2: Staff did not adequately supervise resident in care resulting in resident sustaining injuries. It is alleged that the facility staff failed to adequately supervise Resident #1 (R1), resulting in (R1) leaving the facility without permission and resulting in (R1) sustaining injuries. Reports indicate that (R1) exited the facility unattended around 12:30 PM on Sunday, January 18, 2026. Upon (R1's) return to the facility, nursing staff evaluated (R1) and observed skinned knees, swollen palms, and bruising. This indicates that (R1) wandered out into the community unsupervised and likely fell at some point during the elopement. No further details regarding this incident were provided. On January 26, 2026, between 11:50 AM and 12:00 PM, the Department interviewed with a staff member referred to as Staff #1 (S1). During the interview, (S1) confirmed that on Sunday, January 18, 2026, at approximately 12:36 PM, Resident #1 (R1) left the facility unaccompanied. Video footage from that day shows (R1), who resides in room #345 on the third floor, taking the elevator down to the garage's basement level. (R1) exited through the fire exit door, which was supposed to remain unlocked under City Fire Department regulations, and walked out onto Hayworth Avenue. (S1) explained that the video showed a visitor pressing the elevator call button in the garage while (R1) was inside the elevator. When the elevator doors opened for the visitor, (R1) exited the elevator and left the facility through the fire door. (S1) indicated that, at the time of the incident, the facility had three care staff members working on the third floor and front desk staff monitoring the surveillance security displays. Despite this, (R1) still managed to leave the facility. (Evaluation Report continues LIC 9099-C) Upon returning, (R1) sustained injuries to the knee and palm. Photography of the injuries was shown, and it was confirmed that they occurred during the elopement and not before, according to (S1-S5). Based on information from (S1-S5), it was determined that individual (R1) received first-aid care following the fall. (R1) did not require hospitalization and did not sustain any fractures as a result of the incident. On January 26, 2026, between 11:00 AM and 11:23 PM, the Department interviewed a resident identified as Resident #1 (R1). During the interview, (R1) recalled leaving the facility unaccompanied, but could not recall the exact date and time of the incident. However, (R1) recalled leaving the facility alone, but could not remember what happened afterward. (R1) demonstrated step by step how to call the elevator. (R1) pressed the elevator call button on the third floor and walked in, then pushed the close button. When the elevator doors closed, (R1) waited for the elevator to move, but movement would not occur without entering a code or selecting another floor. (R1) did not proceed to activate any buttons. The elevator was then summoned to the basement garage, and (R1) also showed how to exit the facility through the fire exit door. The Department reviewed the video footage of the incident that occurred on January 18, 2026. The review confirmed the information provided by (S1) that the visitor summoned the elevator at the garage level, which then summoned the elevator car. The footage showed that (R1) exited the elevator and appeared to wander out, looking apprehensive and disoriented. Further analysis of the Unusual Incident Report LIC 624 (dated January 24, 2026) and the Physician's Report LIC 602A (dated September 11, 2025) revealed that (R1) exhibited unsafe wandering behavior and signs of sundowning. Preplacement assessment Information LIC 603 (dated September 10, 2025) (R1) requires special observation/night supervision due to confusion, forgetfulness, and wandering. An analysis of the Unusual Incident Report (LIC 624) (dated 01/24/26), the Physician's Report (LIC 602A) (dated 09/11/25), and Preplacement Appraisal Information (LIC 603) (dated 09/10/25) revealed that (R1) exhibited unsafe wandering behavior and signs of sundowning. This necessitated special observation and night supervision due to confusion and forgetfulness. The records also highlighted the risks of allowing (R1) to leave unsupervised, reinforcing the need for greater supervision. Video footage recorded (R1) shows taking the elevator to the basement and exiting unassisted onto Hayworth Avenue, leading to an unassisted elopement and subsequent injuries. Based on the information gathered, there is sufficient evidence to support the allegation mentioned above. (Evaluation Report continues LIC 9099-C) Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099 D). An exit interview was conducted with Stephanie Brynjolfson, and copies of the report and appeal rights were provided. INVESTIGATION REVEALED THE FOLLOWING: Allegation #3: Staff are not ensuring that resident's hygiene needs are being met while in care. Allegation #4: Staff are not ensuring that resident's clothing needs are being met while in care. Allegation #5: Staff are not ensuring that resident take their medications as required. It is alleged that the facility staff is not ensuring Resident #1's (R1's) hygiene, clothing, and medications are being met while in care. Reports indicated that (R1's) grooming and hygiene, noting that (R1) has been observed without socks, underwear, or bras. Additionally, reports stated that dental care has not been adequately addressed and that personal toothbrushes and toothpaste are unused. Further reports mentioned medication mismanagement and errors, mentioning that a resident had access to Miralax and prescription medications on January 13, 2026. No further details were provided regarding these allegations. On January 26, 2026, and February 12, 2026, between 11:50 AM and 03:45 PM, the Department interviewed staff member identified as Staff #1- Staff #6 (S1-S6). Six (6) out of the six (6) staff members are unable to support these claims. (S1-S6) reported that (R1) requires assistance with bathing, hygiene, grooming, and dressing. They noted that (R1) usually dress independently but occasionally choose not to wear undergarments or accessories. (S3-S6) mentioned that care staff attempt to help (R1) dress appropriately; however, (R1) often refuses their assistance and does not wear suitable clothing. Care staff must respect (R1) 's rights as a resident while also balancing the need to provide necessary care services. (S1-S6) disputed that daily hygiene care is not being provided to (R1). (R1) would conceal personal items, and that may include personal dental supplies provided by family representatives. But it does not verify that (R1's) dental hygiene care is not being met. The facility provides dental supplies (R1), which would take advantage of these complementary services. (S1-S6) reported they could not confirm that (R1) had access to Miralax and prescribed medications. According to (S1-S6), (R1's) management of medications has been consistently error-free. Medications are administered to (R1) exactly as prescribed by the physicians. On January 26, 2026 and February 12, 2026, between 10:50 AM and 12:14 PM, the Department interviewed resident members identified as Resident #1 through Resident #10 (R1-R10). Ten (10) out of the (10) could not corroborate these claims. (Evaluation Report continues LIC 9099-C) (R1-R10), reported no issues or concerns regarding staff assistance with daily hygiene, grooming, and clothing care. Furthermore, they expressed no concerns about the administration or management of their medications. All residents stated that they have not witnessed or experienced any issues of residents having access to medications. (R1-R10) acknowledged the commendable efforts of the staff, particularly regarding the care and supervision services provided. They noted the staff's responsiveness is to be recognized. On March 27, 2026, between 09:23 AM and 10:00 AM, the Department attempted to interview Witness #1 and Witness #2 (W1-W2), who are aware of these allegations; however, they were not available, and calls were not returned. The Department reviewed Resident #1's (R1's) Physician's Report for Residential Care Facilities for the Elderly LIC 602A (dated 09/11/25 & 09/25/25), Comprehensive Assessment/Observation (dated 09/10/25), Service Plan Detail (dated 01/22/26), and Preplacement Appraisal Information LIC 603 (dated 09/10/25) revealed (R1) requires partial assistance with hygiene, clothing, and dental care with care staff prompting assistance. Further review of Physician Order Review (dated 01/22/26) and Medication Administration Record (dated 01/01/26 through 01/31/26) revealed no errors, omissions, or discrepancies. An additional review of staff training records verified staff had completed Workplace Sensitivity Training Courses, including ADLs and Behaviors, Psychosocial Needs, Challenging Behaviors, Basic Essentials, Person Center Care and Medication Management. Based on the information gathered, there is not enough evidence to support the allegations mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated. An exit interview was conducted with Stephanie Brynjolfson, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Apr 6, 2026 · control 11-AS-20260121153025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Apr 13, 2026

87411 Personnel Requirements - General (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required... This requirement is not met as evidence by: Based on interviews and record reviews, the Licensee failed to ensure necessary supervision services to meet resident needs and eloped from the facility unsupervised sustained injuries during the elopment. This violation possesses a potential Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 6, 2026

Plan of correction: Licensee will adhere to the regulations and ensure review of Title 22, Section 87411. The Licensee will develop a Plan to address and resolve the security and safety issues related to (NCD) wandering and elopement behaviors—proof of correction to be sent by fax to the El Segundo Regional office at 424-544-1016 by 04/13/26. Proof of correction submitted 02/13/26.

Allegation investigated: Staff did not adequately supervise resident in care resulting in resident sustaining injuries.

On February 12, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit. Stephanie Brynjolfson admnistrator and Ana Maria Diaz Assistant Director of Health Services greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegation mentioned above. The investigation included interviews, record reviews, and a tour of the facility. Interviews with Staff member S#1 - S#6 (S1-S6) and Resident #2 - #10 (R2- R10). The Department reviewed several documents, including the Facility Resident Roster (dated 01/22/26), the Personnel Report LIC 500 (dated 01/21/26), (R1's) Physician’s Report LIC 602A (dated 9/11/26), the Preplacement Appraisal Information LIC 603 (dated 09/10/25), Unusual Incident Report LIC 624 (dated 01/24/26), Facility Surevillance Camera Footage (dated 01/18/26), and other pertinent records associated with this complaint. (Evaluation Report continues LIC 9099-C) Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #2: Staff did not adequately supervise resident in care resulting in resident sustaining injuries. It is alleged that Resident #1 (R1) sustained injuries due to inadequate supervision by staff. On January 18, 2026, (R1) reportedly eloped from the facility without staff supervision and sustained injuries. Upon (R1's) return to the facility, nursing staff evaluated (R1) and observed skinned knees, swollen palms, and bruising. This indicates that (R1) wandered out into the community unsupervised and likely fell at some point during the elopement. No further details regarding this incident were provided. On January 26, 2026, and February 12, 2026, between 11:50 AM and 01:00 PM, the Department interviewed with staff members identified as Staff #1 through Staff #6 (S1-S6). Five (5) out of the six (6) staff members were able to validate this claim that (R1) sustained injuries during an elopement from the facility. During the interview, staff members (S1-S5) confirmed that on Sunday, January 18, 2026, at approximately 12:36 PM, Resident #1 (R1) left the facility unaccompanied. Upon returning, (R1) sustained injuries to the knee and palm. Photography of the injuries was shown and confirmed that they occurred during the elopement and not before according to (S1-S5). Based on information from (S1-S5), it was determined that individual (R1) received first-aid care following the fall. (R1) did not require hospitalization and did not sustained any fractures as a result of the incident. On January 26, 2026, between 11:00 AM and 11:23 AM, the Department interviewed a resident identified as Resident #1 (R1). During the interview, R1 recalled leaving the facility alone but could not remember what happened afterward. The Department reviewed video footage from that day, which shows (R1), who resides in room #345 on the third floor, taking the elevator down to the garage's basement level. (R1) exited through the fire exit door unassisted by staff, and walked out onto Hayworth Avenue. Further review of the Unusual Incident/Injury Report LIC 624 (dated 01/24/26) verified (R1's) unassisted elopement with injuries. Further review of (R1's) Physician's Report for Residential Care Facilities for the Elderly LIC 602A (dated 09/11/25) (R1) has been assessed, and it is noted that allowing to leave the community unsupervised may present risks related to (R1's) health and mental well-being. (Evaluation Report continues LIC 9099-C) Based on the information gathered, there is sufficient evidence to support the allegation mentioned above. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency were observed, and citation issued (ref. LIC 9099 D). An exit interview was conducted with Stephanie Brynjolfson, and copies of the report and appeal rights were provided. *Immediate Civil Penalty issued* ECP: At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident, the civil penalty shall be ten thousand dollars ($10,000).the state’s words, verbatim · CDSS document, Feb 12, 2026 · control 11-AS-20260121153025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Feb 12, 2026

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all... (2) To be accorded safe, healthful and comfortable accommodations... This requirement is not met as evidenced by: Based on interviews, observation, and record reviews, the Licensee failed to adequately supervise (R1) on 01/18/26, who eloped from the facility and sustained injuries during the elopement. This violation poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 12, 2026

Plan of correction: Licensee/Administrator shall ensure that all staff are trained on elopment and reduce fall injuries resident-specific care plans. The facility will review and update (R1’s) care plan and implement measures to reduce future falls. Documentation of staff training and care plan updates will be submitted to the Department by 02/13/25 to ernand.dabuet@dss.ca.gov **IMMEDIATE CIVIL PENALTY***

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff did not adequately supervise resident in care resulting in resident eloping from the facility.

On January 26, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit. Stephanie Brynjolfson admnistrator a greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegation mentioned above. The investigation included interviews, record reviews, and a tour of the facility. Interviews with Staff member #1 (S1) and Resident #1(R1) . The Department reviewed several documents, including the Facility Resident Roster (dated 01/22/26), the Personnel Report LIC 500 (dated 01/21/26), (R1's) Physician’s Report LIC 602A (dated 9/11/26), the Preplacement Appraisal Information LIC 603 (dated 09/10/25), Unusual Incident Report LIC 624 (dated 01/24/26), Facility Surevillance Camera Footage (dated 01/18/26), and other pertinent records associated with this complaint. (Evaluation Report continues LIC 9099-C) Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff did not adequately supervise resident in care resulting in resident eloping from the facility. It is alleged that the facility staff failed to adequately supervise Resident #1 (R1), resulting in (R1) leaving the facility without permission. Reports indicate that (R1) exited the facility unattended around 12:30 PM on Sunday, January 18, 2026. No further details regarding this incident were provided. On January 26, 2026, between 11:50 AM and 12:00 PM, the Department interviewed with a staff member referred to as Staff #1 (S1). During the interview, (S1) confirmed that on Sunday, January 18, 2026, at approximately 12:36 PM, Resident #1 (R1) left the facility unaccompanied. Video footage from that day shows (R1), who resides in room #345 on the third floor, taking the elevator down to the basement level of the garage. (R1) exited through the fire exit door, which was supposed to remain unlocked under City Fire Department regulations, and walked out onto Hayworth Avenue. (S1) explained that the video showed a visitor pressing the elevator call button in the garage while (R1) was inside the elevator. When the elevator doors opened for the visitor, (R1) exited the elevator and left the facility through the fire door. (S1) indicated that, at the time of the incident, the facility had three care staff members working on the third floor and front desk staff monitoring the surveillance security displays. Despite this, (R1) still managed to leave the facility. On January 26, 2026, between 11:00 AM and 11:23 PM, the Department interviewed a resident identified as Resident #1 (R1). During the interview, (R1) recalled leaving the facility unaccompanied but could not recall the exact date and time of the incident. (R1) demonstrated step by step how to call the elevator. (R1) pressed the elevator call button on the third floor and walked in, then pushed the close button. When the elevator doors closed, (R1) waited for the elevator to move, but movement would not occur without entering a code or selecting another floor. (R1) did not proceed to activate any buttons. The elevator was then summoned to the basement garage, and (R1) also showed how to exit the facility through the fire exit door. The Department reviewed the video footage of the incident that occurred on January 18, 2026. The review confirmed the information provided by (S1) that the visitor summoned the elevator at the garage level, which then summoned the elevator car. (Evaluation Report continues LIC 9099-C) The footage showed that (R1) exited the elevator and appeared to wander out, looking apprehensive and disoriented. Further analysis of the Unusual Incident Report LIC 624 (dated January 24, 2026) and the Physician's Report LIC 602A (dated September 11, 2025) revealed that (R1) exhibited unsafe wandering behavior and signs of sundowning. Preplacement assessment Information LIC 603 (dated September 10, 2025) (R1) requires special observation/night supervision due to confusion, forgetfulness, and wandering. Based on the information gathered, there is sufficient evidence to support the allegation mentioned above. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency were observed, and citation issued (ref. LIC 9099 D). An exit interview was conducted with Stephanie Brynjolfson, and copies of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 26, 2026 · control 11-AS-20260121153025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Feb 9, 2026

87411 Personnel Requirements - General (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required... This requirement is not met as evidence by: Based on interviews and record reviews, the Licensee failed to provide necessary supervision services to meet resident needs and eloped from the facility unsupervised. This violation possesses a potential Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 26, 2026

Plan of correction: Licensee will adhere to the regulations and ensure review of Title 22, Section 87411. The Licensee will develop a Plan to address and resolve the security and safety issues related to (NCD) wandering and elopement behaviors—proof of correction to be sent by fax to the El Segundo Regional office at 424-544-1016 by 02/09/26. Immediate Civil Penalty Issued.

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Resident sustained falls resulting in multiple injuries due to staff neglect. Staff did not meet resident's hygiene needs.

On 10/09/2025, the department conducted a subsequent complaint visit to this facility to conclude the investigation and deliver findings on the above-named allegations. The department met Stephanie Brynjolfson, Administrator, and explained the purpose of the visit. The department was granted access to the facility. The investigation consisted of the following: On 12/04/24, the department requested the following documents: staff roster and resident roster. The department reviewed resident #1 (R1) file, and collected copies of Physician's Report, Identification and Emergency Information, Resident Appraisal, Service Plan (dated: 12/4/2024), and Progress Notes, (dated 11/17/2024-12/01/2024). Additionally, the department conducted a health and safety check and a tour of the entire facility. On 12/09/24, the department conducted an interview with witness #1 (W1). Unsubstantiated On 12/12/24, the department conducted an interview with staff #1 (S1). On 12/13/24, the department conducted interviews with W1, and staff #1-#4 (S1-S4), and attempted to interview residents #2-#3 (R2-R3). On 01/21/2025, the department obtained medical records from Cedar Sinai Medical Center, and on 02/26/25, the department obtained medical records from Victory Hospice for R1. Furthermore, on 02/26/25, the department conducted an interview with staff #5 (S5). On 10/09/25, the department received the following documents: staff roster, resident roster, and Shower Logs for the months of November-December 2024. The department conducted interviews with S3-S4, and residents #4-#12 (R4-R12). Lastly, the department conducted a tour of the facility. The investigation revealed the following: Allegation: Resident sustained falls resulting in multiple injuries due to staff neglect. It is being alleged that a resident sustained two un-witnessed falls while in care, resulting in a fractured wrist, three fractured ribs, and a laceration on forehead due to neglect. The department conducted a review of records. Per Identification and Emergency Information form resident 1 (R1) was admitted to the facility on 08/12/2022 and was initially assessed as ambulatory with the use of a walker. Medical Records from Victory Hospice show that hospice services were initiated for R1 on 10/29/2024. Victory Hospice conducted an assessment of R1, and notes from that assessment state that R1’s health was declining, and that R1 was no longer ambulatory and considered a fall risk. On 11/12/2024, R1 was seen by Registered Nurse #1 (RN1) of Victory Hospice. RN1 stated that a head-to-toe assessment was completed of R1, and that there were no signs of pain. Facility Progress Notes for R1 revealed that on 11/17/24, R1 had an un-witnessed fall and was found on the floor of their room. It was noted that R1 denied hitting their head. An assessment was conducted by facility staff and there were no visible marks noted. R1 was able to move all extremities but complained of back pain and was given Tylenol for pain. The department reviewed visit notes from Victory Hospice. Per the notes R1 was seen by hospice Licensed Vocational Nurse #1 (LVN1) on 11/18/2024 for a follow up after a fall which occurred on 11/17/2024. A physical assessment completed during visit showed a contusion on R1’s lower back. Hospice records noted that there were no other wounds observed and R1 appeared in fair health. Per visit notes from Victory Hospice, on 11/25/2024, R1 was seen by Hospice LVN1. A physical assessment completed during visit showed a contusion on R1’s lower back. Hospice records noted that there were no other wounds observed and R1 appeared in fair health. Per visit notes from Victory Hospice, on 11/26/2024, R1 was seen by RN1, and a head-to-toe assessment was completed of R1. It was noted that R1 displayed signs of depression and forgetfulness, and that there were no signs of pain. The department reviewed Facility Progress Notes which show that on 11/26/2024 R1 was observed with swelling of left wrist. Facility staff contacted Victory Hospice. Further review of visit notes from Victory Hospice dated 11/29/2024, state that R1 was seen by Licensed Vocational Nurse #2 (LVN2) who stated that a physical assessment showed R1 had pain in their left wrist and lower abdomen below the rib cage. R1 flinched when those areas were touched and left wrist displayed redness and swelling. The department reviewed Facility Progress Notes which noted that on 12/01/24 R1 had an un-witnessed fall and was found on the floor of their room. R1 was found lying on the left side of the bed with their head against the corner nightstand. R1 sustained an abrasion on the top left of their forehead, a bruise on their forehead, a red spot under their left eye, a bruise on their left shoulder and a bruise to their left hip. Victory Hospice and responsible party were notified, and R1 was taken via ambulance at 12:30 PM. An Unusual Incident/Injury Report was submitted to the department on 12/05/2024, depicting the same incident and adding that R1 was found around 08:45 AM and was transferred to Cedar Sinai Emergency room for further evaluation after a discussion with residents family. The department reviewed medical records from Cedar Sinai Medical Center, which showed that R1 was admitted on 12/01/2024 and was diagnosed with fractures of the posterior medial left ninth through twelfth ribs with a small left pleural effusion, a nondisplaced fracture of the left wrist, and a four cm left forehead laceration. The department conducted interviews with S1-S5. Of those interviewed, 5 out of 5 staff could not corroborate the allegation. 4 out of 5 staff stated that R1 was moved to the second floor for a higher level of care and supervision. 3 out of 5 staff stated that after the second fall, R1 was provided with a bed that was six inches from the ground with high-low capabilities. An interview with S2 revealed that R1 had their first fall on 11/17/2024 and was found on the floor near their bed. S5 conducted a full body assessment and determined that R1 was able to move all their extremities without concern. After R1’s first fall, facility moved them to the second floor for a higher level of care as second floor of the facility has fall mats, two person assists, and more rotations completed by staff on the residents. S2 stated that R1’s second fall occurred on 12/01/2024 and that S4 found R1 on the floor lying on their left side with their head against the corner of their nightstand. S4 reported to S2 that R1 sustained an abrasion to their top left forehead, and there was a red spot under their left eye. R1 also sustained a contusion on their left shoulder and left hip. Once notified, S2 called Victory Hospice at 0845 hours and left a voicemail. S2 called Victory Hospice again at 0907 hours and reported the incident to Ana at Victory Hospice. S2 then called R1’s Power of Attorney (POA) to inform them of the incident, then called 911 and R1 was transported via ambulance to Cedar Sinai Hospital. The department attempted to interview R2-R3 but was unable to due to cognitive impairment. The department was unable to interview R1, as the resident passed away. An interview conducted with W1 revealed that R1 was at the facility from 08/15/2022 until 12/09/2024. W1 stated that R1 had their first fall on 11/17/2024, and that the facility informed them that that R1 was okay. After the first fall, R1 was moved to the second floor of the facility on 11/25/202 because R1 required a higher level of care. W1 stated that R1 sustained their second fall on 12/01/2024 and during fall R1 hit their head on the nightstand and sustained an abrasion to their forehead. R1 was taken to Cedar Sinai Hospital where they received stitches on their head, and were diagnosed with a left fractured wrist, and three fractured ribs. W1 stated that R1’s bed was changed to a high low bed as it was lower to the ground and that the facility held a conference with them to discuss options for improving R1’s care. Based on interviews conducted, and records reviewed, the department did not find sufficient evidence to support allegation. 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 meet resident's hygiene needs. It is being alleged that a resident was observed with blood in their hair and had not been bathed. On 10/09/25, the department conducted interviews with S1-S4. Of those interviewed, 4 out of 4 staff denied the allegation. 4 out of 4staff said residents receive two showers a week and as needed. An interview with S1 revealed that R1 was showered twice a week, and as needed. S2 stated that Victory Hospice staff was assisting R1 with showers during the months of November 2024-December 2024. On 10/09/25, the department conducted interviews with R4 – R12. Of those interviewed, 4 out of out of 9 residents said that staff are meeting their hygiene and grooming needs, 2 out of 9 residents said they did not know if staff are meeting their hygiene and grooming needs, and 3 out of 9 residents did not answer. 4 out of 9 residents said that staff does assist them with bathing, 3 out of 9 residents said they did not know if staff assists them with bathing, and 2 out of 9 residents did not answer. 6 out of 9 residents said staff has not denied them services, and 3 out of 9 residents did not answer. A review of R1’s Physician’s Report documented under “Capacity for Self-Care” that the resident requires assistance with bathing. A review of the facility’s Shower Logs for the dates of November-December 2024 documented that residents were scheduled for at least two showers a week. The Shower Log for November 2024 documented that R1 received showers from staff at Victory Hospice. There were no showers for the month of December 2024 documented in the Shower Log. On 10/09/25, the department conducted a tour of the facility and observed residents to be clean and free from any odors. Based on interviews conducted, and records reviewed, the department did not find sufficient evidence to support allegation. 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. An exit interview was conducted with Stephanie Brynjolfson, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 9, 2025 · control 11-AS-20241202213733

Type of visit: Case Management - Incident

On July 1, 2025, Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced case management visit. LPA met with Executive Director Stephanie Brynjolfson, and explained the purpose of the visit is in reference to an incident that occurred with Resident #1 (R1) on June 18, 2025. The Department received an Unusual Incident Report LIC 624 on June 25, 2025, regarding an incident that occurred at 7:45 PM. It was reported that Resident #1 (R1) was able to elope from the community unsupervised. (R1) had been admitted to the community on June 17, 2025, and was diagnosed with a Major Neurocognitive Disorder (NCD). (R1) resided on the third floor, known as "the Loft." According to Staff #1 (S1), (R1) had one-on-one private care staff who had taken a break. During this time, S1 informed the Silverado care staff assisting another resident. In a matter of seconds, while the care staff were distracted, (R1) left without supervision. (R1) managed to operate the elevator and descend to the first-floor lobby, passing the front desk receptionist without being recognized, and exited through the front doors. (R1) was found unattended on Fairfax Avenue. (S1) stated that once returned to the community, (R1) had a whole body and skin assessment, saw no signs of injuries or discomfort. (S1) notified the family representative and medical physician of the incident. The Department reviewed (R1)'s Medical Assessment (dated April 17, 2025) and Physician's Order Review. It revealed that (R1) has a history of disorientation and sundowning behavior, which can be associated with wandering and eloping behaviors in residents diagnosed with (NCD). The licensee violates Title 22, Section 87411, Personnel Requirements. California Code of Regulations (Title 22, Division 6, Chapter 8), deficiencies were observed, and citations were issued (ref. LIC 809-D). An exit interview was conducted, and a copy of the Evaluation Report and Appeal Rights was provided to Stephanie Brynjolfson.the state’s words, verbatim · CDSS document, Jul 1, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jul 15, 2025

87411 Personnel Requirements - General (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required... This requirement is not met as evidence by: Based on interview, Licensee failed provide necessary supervision services to meet resident needs and eloped from the facilty unatttended. This violation possesses a potential Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: The Licensee will adhere to the regulations and ensure review of Title 22, Section 87411. The Licensee will provide care staff training to address (NCD) wandering and elopement behaviors—proof of correction, including a sign sheet, to be sent by fax to the El Segundo Regional office at 424-544-1016 by 07/15/25.

Type of visit: Required - 1 Year

On 4/18/2025, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Stephanie Brynjolfson /Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (256) elderly adults ages 60 and above, of which (256) can be non-ambulatory and (92) bedridden. Approved for delayed egress doors and secured perimeters. The facility has an approved hospice waiver for (36). Currently the facility has (115) residents. The facility is a three-story structure located in a residential neighborhood. It consists of (114) residents' rooms, (114) bathrooms, (12) guest restrooms, a lobby, a theater, a gym, a library, a beauty salon, a dining area, a kitchen, a spa, a bistro, (2) wellness rooms, a game room, outside courtyards, two (2) elevators (north and south), and underground parking. LPA Iniguez and the Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (9) bedrooms and (9) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 109.1°F to 112.3°F, and the room temperature ranged from 76°F to 78°F. The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 3/6/25. A review of (6) residents' service files and (6) staff personnel files was maintained in order. LPA reviewed (6) Medication Administration Records (MARs) and found discrepancies. LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance was emailed to LPA. Facility Annual Fess current. Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below: -Facility not following Plan of Operation Regarding Medication documentation. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. * An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Stephanie Brynjolfson /Administrator.the state’s words, verbatim · CDSS document, Apr 18, 2025

Allegation investigated: Staff behavior poses as a risk to a resident while in care. Staff forced a resident to take medication while in care.

On April 14, 2025, the California Department of Social Services Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a visit to gather information regarding the above allegations. LPA met with Stephanie Brynjolfson the Executive Director, and explained the purpose of the visit. LPA was granted entry to the facility. The investigation consisted of Interviews, a collection of records, and a tour of the facility. Interviews were conducted with staff members #1 to #6 (S1-S6), resident members #1 to #10 (R1-R10) and witnesses #1 to #2 (W1-W2). List of documents reviewed/obtained Resident Roster (dated 04/09/25), Personnel Report LIC 500 (dated 04/09/25), (R1)'s Physicians Report LIC 602A (dated 02/21/25), Resident Appraisal (dated 02/17/25), Identification and Emergency Information LIC 601 (dated 02/27/25), and other pertinent documents associated with this complaint. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff behavior poses as a risk to a resident while in care. Allegation #2: Staff forced a resident to take medication while in care. The complaint alleges that the facility staff is unkind and forces Resident #1 (R1) to take medication without informing (R1). As a result of these issues, (R1) feels uncomfortable at the facility. No additional information was provided regarding these allegations. A review of Resident #1 (R1)’s identification and Emergency Information, (dated 02/27/25), indicates that (R1) was admitted to Silverado Senior Living Beverly Place (SSLBP) on that date. Previously, (R1) resided at Belmont Village Westwood from August 2024 to September 2024 and lived independently in a senior living community from November 2024 until February 2025. During (R1)’s time at (SSLBP), several medical visits occurred on March 23, 29, April 1, and April 4, 2025. Three of these four visits were related to the treatment of mental health condition. On April 9, 2025, between 1:15 PM and 2:45 PM, the Department interviewed resident members identified as Resident #1 through Resident #10 (R1-R10). Ten (10) out of the (10) were unable to validate these allegations. (R1) asserted that the conduct of the staff did not present any risk and emphasized that no staff member ever coerced (R1) into taking medications against (R1)'s will. (R1) noted that the staff are kind and attentive, explains the medications, ensure understanding, and encourages questions. (R1) expressed that the feelings of despair stem from the challenges of adapting to assisted living, which significantly diminishes (R1)'s sense of independence and has nothing to do with staff’s behavior. (R2-R10) expressed appreciation for the staff and reported no issues with medication administration. On April 9, 2025, between 9:45 AM and 3:15 PM, the Department interviewed staff members identified as Staff #1 through Staff #6 (S1-S6). Six (6) out of the six (6) staff members were not able to corroborate these allegations. Staff members (S1-S6) reported no issues with the behavior of staff or the way medications are given to (R1). (S4-S6) noted that (R1) asks questions about the medications but has never been forced to take or refuse them. (S1-S3) mentioned that (R1) is adjusting from independent to assisted living environment. It was also noted that (R1) was admitted to Cedar Sinai on April 4, 2025, due to experiencing emotional distress. (S1-S6) confirmed that all staff have received Workplace Sensitivity and Medication Administration training to handle these situations appropriately. (Evaluation Report continues LIC 9099-C) On April 9, 2025, between 11:45 AM and 12:35 PM, the Department interviewed witness members identified as Witness #1 and Witness #2 (W1-W2). Two (2) out of the (2) witness members were not able to verify these allegations. (W1) the Executive Director at Belmont Village Westwood, characterized (R1) as both cooperative and inquisitive regarding medication administration. (W2) a power of attorney for (R1), indicated that (R1) is presently assessing the suitability of assisted living concerning (R1)'s lifestyle needs that may have some reasons for (R1) emotional distress. The Department reviewed Resident #1 (R1) 's Physicians Report LIC 602A (dated 02/21/25) and Resident Appraisal (dated 02/17/25) revealed that (R1) is diagnosed with a mental disorder. Further review of (R1) Physician Order Medication Review (dated 03/23/25 and 04/01/25) and PRN Authorization Letter (dated 02/27/25) identified (R1) cannot determine own need for prescription or nonprescription medications and requires assistance with administration of drugs. (R1) is prescribed eighteen (18) prescription combined prescription and nonprescription medicines and is being treated for (R1) 's mental condition. Twelve (12) of the eighteen (18) medications have adverse side effects or negatively affect (R1) 's mental status (ref: National Institutes of Health - NIH). An additional review of staff training records verified staff had completed Workplace Sensitivity Training Courses, including ADLs and Behaviors, Psychosocial Needs, Challenging Behaviors, Basic Essentials, Person Center Care and Medication Management. During the visit on April 4 and 14, 2025, the Department identified that the facility promotes the rights of its residents. To improve the environment, posters outlining Resident Rights, Personal Rights, and the California Residential Care Facilities for the Elderly Complaint Poster were displayed prominently throughout the facility. Based on the information gathered, there is not enough evidence to support the allegations mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated. An exit interview was conducted with Stephanie Brynjolfson, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Apr 14, 2025 · control 11-AS-20250407092804

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced case management visit regarding the relocation of (45) residents of Silverado Senior Living—Calabasas #197609117 to the facility listed above due to mandatory evacuation orders from Fire Advisory. LPA met with Executive Directors from both facilities, Patrice O'Grady and Stephanie Brynjolfson, and explained the purpose of the visit. LPA conducted a health and safety check during the visit, and no concerns were observed. LPA reviewed and obtained resident and staff rosters for both facilities. Per an interview with Executive Director Patrice O'Grady, (45) residents have been relocated to Silverado Senior-Beverly Place. The facility has sufficient beds, hygiene supplies, bedding, and linens, and everyone has a designated private or shared room with bathrooms in each room. The dining room is large enough to accommodate all residents on the first and second floors. The kitchen has sufficient two-day perishable and seven-day non-perishable food supplies. Medications, MARs, and resident's files of Silverado Senior Living-Calabasas are available electronically. The medicines have been transferred to Silverado Senior-Beverly Place and stored in locked cabinets. (LPA) inspected emergency food and water supplies. LPA observed that the facility has sufficient 30-day Personal Protective Equipment and incontinent supplies. Brynjolfson confirmed that the facility has backup generators. There are (22) ambulatory and (23) non-ambulatory residents transferred from Silverado Senior- Calabasas. There are (32) who use assistive devices, and (43) who require assistance with incontinence care. LPA inspected rooms #242, #246, #317, and #331 and found to be in compliance with Title 22 regulations. The Licensee stated that both facilities use the same vendors, pharmacy, and home health agencies, which allows them to provide the same level of continued care for the residents. (Evaluation Report continues LIC 809-C) There is sufficient staffing available to provide care for residents of both facilities. It has been verified that routine Fire Inspection and Disaster Drills were last tested on 12/15/24. O'Grady confirmed that all families and responsible parties of Silverado Senior-Calabasas residents have been notified about the relocation either via calls or emails. O'Grady confirmed that residents from Siliverado Senior-Calabasas were health screened prior to the relocation. An exit interview was conducted, and Executive Directors Brynjolfson and O'Grady were provided with a copy of this report.the state’s words, verbatim · CDSS document, Jan 10, 2025

Allegation investigated: Staff handles residents in a rough manner. Staff did not ensure that a resident's incontinence needs were met. Staff do not ensure that residents' dietary needs are met. Staff do not monitor residents for change in condition. Staff did not provide resident with clean linen. Staff did not report incident to appropriate parties.

On 11/10/24, California Department of Social Services/Community Care Licensing (CDSS/CCL) associate conducted a subsequent unannounced complaint visit. (CDSS/CCL) associate was greeted by Director of Resident & Family Services Krystal Milosevic. (CDSS/CCL) associate explained the purpose of this visit was to deliver findings for the allegations mentioned in this complaint. The investigation consisted of the following: An initial complaint investigation/health and safety visit on 12/26/23, interviews, and collection of records. Interviews with Staff #1-#5 (S1-S5), Residents #1-#10 (R1-R10) and Witness #1 (W1). review of Personnel Report LIC 500 (dated: 12/26/23), Registered of Faciltiy Resident Roster (dated: 12/26/23),Service Plan (dated: 09/09/23 & 12/18/23), Physician Report LIC 624A (dated: 02/16/23), Incident Report LIC 624 (dated: 12/22/23), Facility NOC Resident Assignment/Resident Care Schedule (dated: 12/01/23-12/19/23), and Caregiver Daily Rounds Schedule (dated: 12/01/23-12/19/23), Resident’s Dietary Report (dated: 12/26/23), and email correspondences (dated: 12/18/24). (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff handles residents in a rough manner. The details of the complaint alleged that staff handled (R1) in a rough manner. It is reported that staff #3-#4 were involved in an incident with (R1) on 12/17/23, where (R1) fell and sustained a left arm injury. Further details provided the incident took place during (R1’s) vital checks was taking place and that (R1) became unsettled and aggressive and that (S4) pushed (R1) down causing a fall and sustained injury. On 12/26/23, between 01:30 pm – 04: 00 pm, the Department interviewed (2) out of (3) who claimed this accusation was false. (S1) stated that an investigation on this matter concluded and no findings of abuse were found. (S1) described on an Incident Report LIC 624 (dated: 12/22/24), that (R1) was restless and aggressive with (S4), and a body movement with (R1) caused (R1) to lose balance and fall back. (S1) indicated (S3 and S4) interviews resulted in no negative feedback on care concerns or work performance about (S3). (S3) claimed to have not been observed how (R1) fell. (S3) claimed that staff #4-#5 (S4-S5) were both assisting (R1) on 12/17/24 when the fall incident took place. (S5) reported the incident to (S3) in which (S5) provided inconsistent times when the incident occurred. (S3) claimed that there were tensions between (S4 and S5) and did not get along and may have given inaccurate reporting of what occurred. (S3) assessed (R1) and noted a skin tear on the lower left arm due to the range of motion and found no head injury. (S3) stated first aid treatment was administered for the skin tear. (S4 and S5) were not available for an interview or comments on this matter. On 12/26/23, between 10:00 am – 01:00 the Department interviewed (7) out of (10) residents could not corroborate this allegation. Seven (7) out of ten(10) residents stated the facility staff provided acceptable services, complimentary, and had not experienced any mistreatment. (R9-R10) refused to be part in an interview. As a result of the Department reviewing (R1’s) Service Plan (09/09/23 & 12/18/23), Physician Report LIC 624A (dated: 02/16/23), Incident Report LIC 624 (dated: 12/22/24), revealed that (R1’s) mental condition is associated with behavior disturbance, anxiety, depression, sundowning, and a fall risk. Based on the gathered information, there is not enough evidence to support the allegation mentioned above. (Evaluation Report continues LIC 9099-C) Allegation #2: Staff did not ensure that a resident’s incontinence needs were met. Allegation #4: Staff do not monitor residents for change in condition. The details of this complaint alleged that staff do not ensure resident #1 (R1) incontinence needs are met. Information provided claimed that (R1) is not being checked every two hours or checked throughout night hours for diaper changes. This coincides with a report that staff do not monitor residents' changes in condition due to incontinent services. On 12/26/23, between 01:30 pm – 04: 00 pm, the Department interviewed (2) out of (3) staff #1-#3 who claimed this accusation was false. (S3) claimed to have experienced that when resident refuses service the staff will send a new face, and they will accept our assistance. (S3) stated that (R1) is often upset and refuses the staff to assist with (R1’s) toileting needs. The staff would often send new faces that (R1) is familiar with and will allow for assistance. According to (S3), the residents are not in the right frame of mind and do not want to be groomed or not feeling well. As soon as they tell me they feel dizzy, I will take their vital signs to ensure everything is okay. Residents' hydration is monitored and assisted by caregivers. I look at their color, their lips, and their skin. If they appear to be dry, they need more liquids. For instance, if residents show elevated blood pressure, that's the first sign of dehydration. (S4 and S5) were unavailable for an interview or comments on this matter. On 12/26/23, between 10:00 am – 01: 00 pm, the Department interviewed (7) out of (10) residents could not corroborate this allegation. Seven out of ten (10) stated the facility staff provided adequate incontinent services or had no issues. Seven (7) out of ten (10) claimed the staff do monitor their change in condition and had no concerns on this matter. (R9-R10) refused to take part in an interview. As a result of the Department reviewing (R1’s) Service Plan (dated: 09/09/23 & 12/18/23), Physician Report LIC 624A (dated: 02/16/23), Incident Report LIC 624 (dated: 12/22/23), Facility NOC Resident Assignment/Resident Care Schedule (dated: 12/01/23-12/19/23), and Caregiver Daily Rounds Schedule (dated: 12/01/23-12/19/23), revealed that (R1’s) required assistance with toileting. However, (R1) did not require continuous bed care, had no history of skin condition or breakdown, and monitoring, repositioning, and diaper changes were performed on (R1). Based on the gathered information, there is insufficient evidence to support the allegation mentioned above. (Evaluation Report continues LIC 9099-C) Allegation #3: Staff do not ensure that resident’s dietary needs are met. A resident's diet was allegedly not provided according to the details of this complaint. It is reported residents are not provided with water or snacks. They were no further detailed information on this matter. On 12/26/23, between 10:00 am – 01:00 pm, the Department interviewed (7) out of (10) residents could not support this allegation. Seven (7) out of ten (10) were complimentary of the food and claimed it was pleasing, and ample refreshments and snacks were offered throughout the day. Two (2) out of ten (10) residents claimed to be on a special diet and that their dietary needs were fulfilled. (R9-R10) did not want to take part in an interview. On 12/26/23, between 01:30 pm – 04: 00 pm, the Department interviewed (2) out of (3) staff who claimed this allegation is untrue. (S3) stated most of the residents are on a mechanical so diet, while some are on puree. The kitchen creates individual special orders for those on special diets as well according to their care plan. (S3) reported that plentiful water and snacks are provided during mealtimes. As a result of the Department reviewing (R1’s) Service Plan (dated: 09/09/23 & 12/18/23), Physician Report LIC 624A (dated: 02/16/23) and Resident’s Dietary Report (dated: 12/26/23), revealed that (R1) was not on any special diet and no medical history of due to dehydration or malnourishment. Based on the gathered information, there is insufficient evidence to corroborate the allegation mentioned above. Allegation #5: Staff did not provide resident with clean linen. The detail of this complaint alleged that staff do not provide residents with clean linen. It is reported due to the abundant of incontinent activities, the residents are not provided with clean linens. There were no further details on this matter provided. On 12/26/23, between 01:30 pm – 04: 00 pm the Department (2) ou of (3) staff who claimed this accusation was fabricated. (S3) claimed the caregivers have a schedule of linens. We don't wash that with their personal clothing as sometimes people do have accidents. There are ample linens provided to our residents in care. Linens are provided daily or as needed to residents according to (S3). On 12/26/23, between 10:00 am – 01: 00 pm, the Department interviewed (7) out of (10) residents. could not attest this allegation. Seven (7) out of ten (10) stated that linens are changed regularly or had no concerns on this matter. (R9-R10) refused to take part in an interview. (Evaluation Report continues LIC 9099-C) As a result of the department observation during the investigation on 12/26/23, the Department observed storage closets filled linens, and the linens observed appeared to be clean and presentable. Based on the gathered information, there is insufficient evidence to corroborate the allegation mentioned above. Allegation #6: Staff did not report incident to appropriate parties. The details for this complaint alleged the incident with resident #1 (R1) on 12/17/24 was not reported to the appropriate parties. The reports claimed the (R1’s) family was provided false information on (R1’s) fall incident and gave inaccurate information on how (R1) sustained the arm injury. On 12/26/23, between 01:30 pm – 04: 00 pm the Department interviewed (2) out of (3) staff claimed this accusation was false. (S3) stated in general when an incident occurs, after we handle the situation, the nurse on call, will dispatch for assistance to call 911. Paramedics arrive and I provide them with paperwork. I inform the responsible parties by telephone. I provide written information to (S1) and it is cross reported to authorized parties. (S1) claimed the incident was reported in an Incident Report LIC 624 (dated: 12/22/24) to authorized representatives appropriately. On 12/26/23, between 10:00 am – 01: 00 pm the Department interviewed (7) out of (10) residents could not validate this allegation. Seven (7) out of ten (10) stated the facility followed proper protocol and reports to authorized representatives. (R9-R10) refused to take part in an interview. As a result of the Department reviewing (R1’s) Incident Report LIC 624 (dated: 12/22/24 and the facility’s email correspondences (dated: 12/18/24) revealed incident involving (R1) was discussed, investigated, and reported to (R1’s) authorized representatives. Based on the gathered information, there is insufficient evidence to corroborate the allegation mentioned above. Between 12/26/24 - 01/10/24, the Department attempted to interview family representative witness #1 (W1) of (R1) by telephone who were unavailable for statements. Between 12/26/24 - 01/10/24, the Department made several attempts to interview staff #4 and #5 by telephone and were unavailable for comments. Due to the resident's passing on 12/23/23, the Department was not able to obtain statements from Resident #1 (R1). (Evaluation Report continues LIC 9099-C) Based on information gathered, an inspection of the facility, observation, and interviews conducted, an analysis of records reviewed, the Department found no evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with Director of Resident & Family Services, Krystal Milosevic, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Nov 10, 2024 · control 11-AS-20231219112612

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sparkle Day conducted a Case Management site visit to the facility to ascertain information pertaining to the Licensee-initiated Incident Report which occurred on 09/06/2024. LPA met with Staff #1 Administrator Stephanie Brynjolfson who assisted with the visit. On 9/6/24 at 8:15am resident #1 (R#1) received incorrect dosage of Ativan from Silverado Hospice RN, W#1 Jane Edwards. R#1 was expected to take a dosage of .025 of Ativan and was administered a dosage of 2.5 mg of Ativan. Immediately after administering incorrect dosage of Ativan to R#1, the Hospice Nurse informed the Nurse at the Nurse station Staff #2 Maria Gabriel who informed the Asst Director of Health Services , The Health Services Director, the Physician and the family. During todays visit LPA interviewed Administrator Stephanie Brynjolfson Staff #1, Director of Health Services Staff #3, Tommy Anderson and Asst Director of Health Services Staff #4 , Maria Roldan], Facility staff then followed Physician instructions Assessed and monitored R#1. LPA reviewed the following current staff training : Identifying and Managing Medication Errors and Adverse Consequences dated 9/20/24 ,Administering Medications to Hospice Residents instead of Hospice nurses dated 9/9/2024 and Resident Medication distribution dated 9/20/24 LPA observed a new policy of the facility regarding Medication distribution with Hospice nurses indicating whenever a resident is on hospice and needs medication the hospice nurse will communicate the information to the Silverado Beverly Place charge nurse. At that time the charge nurse will verify all orders and administer the medication to the residents. LPA Day obtained a Memo from R#1 physician that indicated that Ativan can be used at the dosages of 2 to 6 mg daily with the maximum of 10 mg daily and does not feel that the 2.5 mg dosage would led to the demise of R#1. LPA did not observe deficiencies therefore no citations were issued at this time. LPA requested the death certificate from the facility. An exit interview was conducted, a copy of the Report were provided to Administrator Stephanie Brynjolfson .the state’s words, verbatim · CDSS document, Sep 25, 2024

Allegation investigated: Facility staff mishandled resident's medications Facility is understaffed Incomplete admission documents

Licensing Program Analyst (LPA) Sparkle Day conducted a “Subsequent” visit to ascertain additional information regarding the above-mentioned allegation(s) and for the purpose of rendering the findings. LPA met with Staff #1 Administrator,Stephanie Brynjoyfson who assisted with the visit. The Investigation consisted of the following: Regarding Allegation #1, FACILITY STAFF MISHANDLED RESIDENTS MEDICATIONS It was alleged that the facility gave wrong medication to a resident. On 7/2/2024 at approximately 11:06am - 12:00pm LPA interviewed Resident #1- R#7. 7 out of 7 residents deny the allegation. Residents state medications are given timely daily and they have never been given the wrong medications. LPA interviewed Staff #1 - S#5 at approximately 11:30am - 12 :00 pm . 5 out 5 staff deny the allegation. Staff state medication is double checked by med tech and LVN prior to distribution of meds daily. LPA Day reviewed the medication Administration records and did not observe any discrepencies. Based upon this investigation , LPA finds that 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. Unsubstantiated Regarding Allegation #2, FACILITY IS UNDERSTAFFED It was alleged that there is a staffing problem on the 3rd floor of the facility. On 7/2/2024 at approximately 11:06 LPA interviewed Resident #1- R#7. 7 out of 7 residents deny the allegation. Residents state there is always enough staff on the 3rd floor to meet their needs. LPA interviewed Staff #1 - S#5. 5 out 5 staff deny the allegation. Staff state the 3rd floor is the LOFT where the residents are pretty independent and don't require alot of care, however staff are always there to assist and supervise residents. LPA toured the 3rd floor (The Loft) and found the residents are independent and don't require much assistance. LPA observed that there is a 1 -7 staff to resident ratio on the 1st floor, A 1-6 staff to resident ratio on the 2nd floor and 1 - 6 staff to resident ratio on the 3rd floor. All floors have a 5 staff standby resident assistance if needed. Based upon this investigation , LPA finds that 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]. Regarding Allegation #3- Incomplete Admission documents It was alleged that the facility is not giving residents or residents' families all necessary documents during admission. 0n 7/2/2024 at around 11:50 am LPA interviewed Staff #1 - S#5 regarding the allegation. 5 out of 5 staff deny the allegations. Staff state that all residents and/or residents families are given a copy of their admission documents at time of admission with their signatures. Staff informed LPA that residents have a choice of receiving a paper packet of their signed admission documents or they can get their documents Docu Sign, in which the documents are emailed to them with their signatures. LPA interviewed Resident #1 - R#7 regarding this allegation. 5 out of 7 residents deny the allegation and state they were given copies of everything signed at admission. The other 2 residents do not recall. Based upon this investigation , LPA finds that 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. Exit interview conducted with A copy of this report was left withthe state’s words, verbatim · CDSS document, Jul 2, 2024 · control 11-AS-20220901144128

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs)/Retired Annuitants (RAs) Sparkle Day and Elizabeth Ceniceros conducted an unannounced Annual Random site visit using the CARE Inspection Tool. LPAs/RAs conducted a risk assessment with Staff #2 (S2: Jasmine Garcia). Staff #2 informed LPAs/RAs that the facility has no COVID cases nor do the residents or staff have symptoms. LPAs/RAs met with the Director of Operations/Administrator (A1: Taylor Giunto), Staff #1 (A2: Stephanie Brynjolfson, Family Ambassador), and Staff #3 (S3: Maria Diaz-Anna, Assistant Director of Health Services). LPAs/RAs explained the purpose for today’s visit. The facility is licensed to operate for (256) non-ambulatory elderly adults of which (92) may be bedridden - ages 60 and above. Currently, the facility has (112) residents and (14) in hospice care. The facility is approved for (36) hospice residents. The facility is a three-story structure located in a residential neighborhood. It consists of the following: (114) residents' rooms, (114) bathrooms (12) guest restrooms, a lobby, a theater, a gym, a library, a beauty salon, a dining area, a kitchen, a spa, a bistro, (2) wellness rooms, a game room, outside courtyards, two (2) elevators (north and south) and underground parking. LPAs/RAs Day and Ceniceros toured the facility and observed residents in care. There were no bodies of water on the premises. The following residents’ rooms were inspected: #133, #145, #146, #217, #219, #220, #242, #248, #318, #325, #324. Bathrooms were operational with water temperature measuring at 107*F – 112*F degrees. LPAs/RAs observed beds and bedding supplies to be in good condition, adequate lighting, and sufficient storage for residents’ personal belongings. Bed linens, comforters, and bath towels are fully stocked and stored in cabinets. There is a comfortable room temperature maintained in the facility within 74.0*F – 76.0*F degrees. LPAs/RAs Day and Ceniceros observed the facility to be furnished at the time of this visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharp objects were stored and inaccessible to residents in care. The commercial-size kitchen was inspected and there is a sufficient food supply of perishables and non-perishables. Facility’s smoke detectors and carbon monoxide systems are inter-connected (w/back-up battery) can be observed in the hallways and rooms. LPAs/RAs observed a pull-switch, fire alarm sounding device observed in the hallway/main entrance. Fire extinguishers are fully charged with posted signs. First-aid kits are fully stocked (w/first-aid manual). The last fire drill was conducted on 02/23/24. LPAs/RAs Day and Ceniceros reviewed Residents #1 - #11 Medication Records Administration (MAR) and observed the MAR to be maintained in an electronic health records system. LPAs/RAs observed the facility's infection control practices and also the screening protocols for visitors, staff, and residents. LPAs/RAs observed: sanitizing stations in common areas and restrooms; multiple first-aid kits maintained in order and complete with required items; a 30-day supply of Personal Protective Equipment (PPE); and all mandated inspection control posters posted at the main entrance. LPAs/RAs Day and Ceniceros conducted an audit of Residents (R1 - R11) records and Staff (S1 - S11) personnel files/training records that are in complete order. LPAs/RAs conducted random interviews of five (5) residents and five (5) staff members. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPAs/RAs did not observe deficiencies, therefore no citations were issued at this time. An exit interview was conducted and a copy of the Facility Evaluation Report was provided to the Regional Director of Operations/Administrator (A1: Taylor Giunto) and Family Ambassador/Administrator (A2: Stephanie Brynjolfson).the state’s words, verbatim · CDSS document, Apr 10, 2024