Silverado Brea

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

Type of visit: Case Management - Incident

On August 10, 2026, at 9:00 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced Case Management Visit to follow-up on an incident report received from the facility. LPA Kim was greeted by Administrator Sheila Fike and LPA Kim explained the purpose of the visit. ADMIN Fike stated they could not stay for the visit and stated Office Manager Mayte Carranza could sign on behalf of the facility. During today’s visit, LPA conducted a tour of the facility . Facility is maintained at a comfortable temperature for the residents in care. LPA obtained Staff Roster, Resident Roster, and R1’s records which includes the Physician’s Report, Emergency Information, Appraisal and Needs/Service Plan, and other pertinent documents. Based on interviews conducted, two staff stated that there were lesions and blisters on R1's private area. After being discharged from the hospital, two staff stated that R1 was diagnosed with a Urinary Tract Infection (UTI) and returned to the facility safely. Based on record review, Incident Report dated August 5, 2026, received by CCLD DSS Orange County Regional Office, about R1 having a blister or lesion on their private area. Hospital After Visit Summary Report dated August 5, 2026, diagnosed R1 with Urinary Tract Infection (UTI). No deficiencies were observed during this visit. An exit interview was conducted, and a copy of this report was provided to the Office Manager Mayte Carranzathe state’s words, verbatim · CDSS document, Aug 10, 2026

Allegation investigated: Resident sustained unexplained injuries while in care. Medications are accessible to residents in care. Residents hygiene needs are not being met. Facility staff did not provide adequate supervision resulting in a resident consuming another resident's medication. Residents bedding is left soiled for a long period of time. Facility is falsifying medication log. Resident was left in the same clothing for a long period of time.

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to investigate the above mentioned complaint allegations. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Ashiman Gill And discussed the purpose of the visit. The investigation into the allegation of resident sustained unexplained injuries while in care revealed the following: LPA observed a physicians report for Resident #1(R1) dated August 18, 2021, stating that R1 was ambulatory, was able to feed, bathe, dress and groom self with minimal assistance and did not have a history of a skin condition or breakdown. LPA observed facility progress notes for R1 from January 16, 2023 to June 14, 2023, stating that on May 9, 2023 a large bruise was noticed on their right thigh with no falls reported. LPA observed routine wellness observations and observed that on March 20, 2023 R1 had a bruise on both elbows due to a fall. LPA observed that on July 20, 2023, R1 had a bruise noted on their inner left shoulder with no reason noted. Three of four staff interviews revealed that R1 bruised easily and they could not recall a specific time when a bruise was notated. Continue on 9099C Unsubstantiated LPA was unable to interview R1 due to not residing at the facility. Although the complaint allegation was deemed UNSUBSTANTIATED, LPA observed an in service of updated staff training dated September 16, 2025, that covered topics of preventing bruising/pressure injuries. Regarding the facility allegation of medications are accessible to residents in care and facility is falsifying medication log revealed the following: It was alleged that staff are leaving medications in a room unattended making the medication accessible to residents in care and that facility staff threw away medication after a resident refused to take it, but told staff that it had been administered. Interviews with three of three staff revealed that the facility nurse is the only one that passes medications and marks off the medication log and that they stand there and ensure the resident takes their medications before moving on. Three of three staff could not recall a time where medications were ever accessible to residents in care or when the medication log had been falsified. Although the complaint allegation was deemed UNSUBSTANTIATED, LPA observed a medication security policy that was reviewed and signed by facility staff on March 27, 2025 and April 1, 2025. LPA reviewed resident medication and observed it to be administered according to physicians orders at the time of the investigation using the facility electronic medication administration record. Regarding the facility allegation of residents hygiene needs are not being met revealed the following: It was alleged that residents were not given showers for three weeks. Two of three staff informed LPA that when a resident refuses to take a shower, they will try again later. If the resident keeps refusing, they will try again on the next shift. Two of three staff informed LPA that they will keep asking the resident, but will not force them to take a shower. LPA did not observe shower logs for residents in care. Although the complaint allegation was deemed UNSUBSTANTIATED, LPA observed staff training covering bathing a person with dementia last done in the year 2024 for three of three staff. Regarding the facility allegation of residents bedding is left soiled for a long period of time revealed the following: It was alleged that facility staff left Resident #2(R2) in their soiled bed for three weeks. LPA reviewed a physicians report dated January 1, 2023, stating that R2 was diagnosed with dementia, does not require continuous bed care, did not have bladder or bowel impairment, was unable to communicate their needs, was able to care for their own toileting needs and was considered non ambulatory. Two of three staff informed LPA that residents are checked for brief changes every two hours unless needing a changing sooner. Two of three staff informed LPA that caregivers are able to change residents sheets even if they are still in the bed. Two of three staff informed LPA that R2 was difficult to change, but the staff never left them soiled for an extended period of time. Continue on 9099C The Department attempted to interview R2, but they could not confirm or deny the allegation. Although the complaint allegation was deemed UNSUBSTANTIATED, LPA observed a staff in-service training that was conducted on September 16, and September 29, 2025, covering topics such as bed making, perineal care, and bowel movement protocol. LPA observed residents to be out of their rooms and appeared to be cleaned. LPA did not observe a smell throughout the facility due to residents hygiene needs not being met or residents being left soiled for a long period of time. Regarding the allegation of facility staff did not provide adequate supervision resulting in a resident consuming another resident's medication revealed the following: It was alleged that Resident #3 (R3) drank Resident #4(R4) medication that was crushed and put in their drink. LPA reviewed a physicians report dated November 4, 2021, stating that R3 was diagnosed with dementia and was able to feed themselves. LPA did not observe an updated physicians report for R3. LPA reviewed a physicians report dated November 21, 2022 for R4 stating that R4 was diagnosed with dementia and is able to feed themselves. LPA did not observe an updated physicians report for R4. Three of three staff informed LPA that they do not walk away from the resident until all the medication has been consumed to ensure that another resident does not pick up their cup. One of three staff informed LPA that R2 is unable to drink unassisted, so staff would help them drink the juice with their medication. The Department attempted to interview R3 and R4 and they could not confirm or deny the allegation. Although the complaint allegation was deemed UNSUBSTANTIATED, LPA observed updated staff medication training dated June 8, 2025, and October 29, 2025, for two of three staff. One of three staff does not do medication distribution in the facility. LPA did not observe medications accessible to residents at the time of the investigation. LPA observed the medication room and the medication cart to be locked on both of the facility floors. Regarding the facility allegation of resident was left in the same clothing for a long period of time revealed the following: It was alleged that Resident #5(R5) was left in the same clothing over an entire weekend without being changed. LPA reviewed a physicians report dated April 27, 2022, for R5 stating R5 was diagnosed with dementia and was able to dress/groom themselves. LPA did not observe an updated physicians report for R5. Two of three staff informed LPA that R5 wore similar clothing everyday which included a tshirt and levi jeans. Two of three staff informed LPA that R5 looked the same everyday due to their clothing being so similar. LPA was unable to interview R5 due to them not residing at the facility. Although the complaint allegation was deemed UNSUBSTANTIATED, LPA observed three of three staff have resident personal rights training completed in 2024. Continue on 9099C Based on information gathered, interviews and record review, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegations are deemed UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was provided at the time of the investigation.the state’s words, verbatim · CDSS document, Jan 6, 2026 · control 22-AS-20230706102447

Type of visit: Case Management - Incident

Licensing Program Analysts (LPA)s Hanna Gough and Rose Ruppert made an unannounced Case Management visit to follow-up on an Unusual Incident Report received in the Regional Office. LPAs were greeted and granted entry by the Concierge at 8am. LPAs obtained the following documentation for Resident #1 (R1): Identification and Emergency Information Form, Physician's Report, Resident Appraisal, Assessment, Service Plan Detail and Facility Progress Notes. LPA reviewed three of three staff files and obtained a copy of an employee Notice of Disciplinary Action. Per review of R1's Physician's Report dated 01/19/2022, R1 is diagnosed with Alzheimer's Disease. R1 is confused/ disoriented, has wandering behavior and is unable to leave the facility unassisted. The appraisal, dated 8/15/2024, states R1 wakes during the night searching for a family member. R1's Service Plan Detail, dated 2/11/2025 states R1 is exit seeking and a Care Conference was held with R1's Responsible Party on 2/14/2025 to discuss the updated care needs. LPAs reviewed the Unusual Incident Report submitted to the Regional Office by the facility for an incident that occurred on 9/25/2025 at 4:50am. R1 activated the delayed egress alarm and walked away from the stairwell. The night staff silenced the stairwell alarm but did not reactivate stairwell alarm. R1 engaged with staff in a hallway before entering the stairwell and exiting the facility to the sidewalk. Faciity staff initiated elopement procedures and were unable to locate R1 and contacted 9-1-1. During the call the dispatched Brea Police Department (PD) located R1 next door and returned R1 to the (Continued on LIC 809-C) (Continued from LIC 809) community and staff conducted a full body assessment and vitals were at baseline and no injuries were noted. Staff contacted Responsible Party (RP) regarding the elopement and a 1:1 personal companion was provided for R1 overnight. LPA also interviewed R1 on a health and safety check. Based on LPA's record review, observations and interview, the facility failed to secure exterior doors and alarms for dementia residents in care. A deficiency and immediate $500 civil penalty are being given per California Code of Regulations 87705(d). An exit interview was conducted with Tana McMillon, Regional Vice President of Operations, and copy of this report, LIC 809-D, LIC 421IM, LIC 811, LIC 859 and Appeal Rights were provided to the facility.the state’s words, verbatim · CDSS document, Oct 28, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(d) · Plan of correction due date: Oct 29, 2025

87705 Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, This requirement was not met as evidenced by: Staff did not ensure exterior doors were secured which resulted in a resident eloping from the community. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: Administrator (AD) has conducted an elopement drill and inservice with all staff members. by POC date. The staff member who left the exterior door unsecured no longer works at the community. AD will email LPA documentation that all staff know how to use the exterior door keypads/locks to secuire the community.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry and met with Tana McMillon, Regional Vice President of Operationsr at 12:30pm and explained the purpose of the visit. The facility is a two-story building with a capacity of seventy non-ambulatory residents; of which twenty-five may be bedridden. The facility is divided into two communities. The first level is the Birch community and the second level is the Peppertree community. The facility currently has a census of forty-three residents in care. During today's visit, LPA toured the facility and inspected the physical plant. LPA tested hot water temperatures in five of five resident bathrooms. The hot water temperature measured between 107.9 and 113.0 degrees Fahrenheit. Resident apartments had the required furnishings and were clean with no hazards observed. The fire sprinklers, smoke alarms and carbon monoxide detectors are tested annually and were tested on October 17, 2024. The next test is scheduled for November 11-12, 2025. The Director of Plant Operations (DPO) will email LPA with results from the November 11-12, 2025 inspection. There are fourteen fire extinguishers throughout the community and they were charged and were serviced on May 21, 2025. The facility’s last fire drill was conducted on September 7, 2025 and evacuation chairs were observed in stairwells. LPA and DPO tested the delayed egress doors in the Birch neighborhood and egress door released after thirty seconds. (Continued on LIC 809-C) (Continued from LIC 809) LPA inspected the kitchen food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. The walk-in refrigerator had a variety of fruits and vegetables and a temperature log is updated daily. The kitchen is secured with a keypad so only staff are able to enter. Knives are secured in the kitchen. Emergency supplies were in the storage room and water is stored outside. Hazardous chemicals are stored in a locked storage room. The Birch Community has a meditation room/theater and residents were observed listening to soothing music in the common area. There is a courtyard where residents and family members were visiting and there were shaded seating areas. The were no hazards obstructing hallways or walkways. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. First Aid Kits were observed in the medication rooms with the required elements. LPA pressed a resident pendant and staff came within five minutes to assist. LPA reviewed five of five staff training and fingerprint records and reviewed five of five resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that the administrator has a current administrator certificate which expires on November 18, 2026. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Tana McMillon, Regional Vice President of Operations and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.the state’s words, verbatim · CDSS document, Oct 21, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced case management visit to amend findings for Complaint Control # 22-AS-20250819122622; which was delivered on August 28, 2025. LPA was greeted and granted entry by the receptionist and met with Administrator (AD) Ashiman Gill and explained the purpose of the visit. LPA explained to AD Gill that the complaint finding of Unsubstantiated is being amended to Unfounded. An exit interview was conducted with AD Gill and a copy of the amended findings and this report was provided to the facility.the state’s words, verbatim · CDSS document, Sep 16, 2025

Allegation investigated: Resident fell due to lack of care and supervision

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to investigate a complaint received in the Regional Office. LPA met with Ashiman Gill, Administrator and explained the purpose of the visit. It was alleged that a Resident fell due to lack of care and supervision on August 19, 2025. LPA obtained the following documents for Resident #1 (R1): Resident roster, August 2025 staff schedule, Unusual Incident Report for 8/19/2025, Identification and Emergency Information, Physician's Report, Service Plan Detail, Progress Notes, Facility Fall protocol, behavior mapping and additional medical documentation. LPA conducted a health and safety check on residents in care who looked forward to a facility luau to take place at 12pm-2pm. LPA toured R1's room and observed there were no hazards or obstacles. LPA interviewed R1 who stated they were doing fine and gave LPA a thumbs up sign. (Continued on LIC 9099-C) ****THIS IS AN AMENDED REPORT**** Unfounded (Continued from LIC 9099) The Physician's Report dated 1/17/2025 states R1 has a diagnosis of dementia. Upon questioning, R1 could not recall a recent fall that occurred. R1 stated they enjoyed their breakfast but could not recall what they ate for breakfast. LPA interviewed two of two witnesses, four of four staff and Resident #1 (R1) regarding the fall incident. Two of four staff members were present at the time of the fall. One staff member witnessed R1 sitting on the bed and then R1 losing their balance and falling to the floor. The other staff member heard the fall and headed to the area and the nurse immediately followed. LPA reviewed video footage and obtained photos of time stamps regarding the incident. Staff interviews indicated R1 had a witnessed fall at 7:42am. Camera footage shows staff member stepping out of the room and within a minute's time, a second staff member and then the nurse are observed going into the room. Staff notified Responsible Party (RP) and paramedics were on-site by 7:57am. LPA reviewed the documents and an updated assessment was conducted on August 13, 2025 regarding R1. An Unusual Incident Report was filed with the Department by the facility and resident returned on same day. Upon return, a personal 1:1 caregiver was provided to observe R1 from 8pm to 8am and Behavioral mapping of nighttime activities was completed. Based upon LPA observations, interviews, records and video review the allegation that a Resident fell due to lack of care and supervision is Unfounded. The allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted with Ashiman Gill, Administrator, and a copy of this report was provided to the facility. ****THIS IS AN AMENDED REPORT****the state’s words, verbatim · CDSS document, Aug 28, 2025 · control 22-AS-20250819122622

Allegation investigated: Staff are not following reporting requirements Staff falsified residents' medication record

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an investigation into a complaint received in our Regional Office. LPA met with Ashiman Gill, Administrator (AD) and explained the purpose of the visit. The purpose of the visit is to investigate an incident on Sunday, July 13, 2025 at 5:40pm that a resident was given the wrong medication. LPA requested the following documents: Staff roster with phone numbers, Current staff schedule, and facility Medication Policy. LPA requested copies of Resident #1 (R1) and Resident #2 (R2)'s: Identification and Emergency Information, Care Plans, Physicians Reports and Medication Administration Records (MARs). LPA also requested in-service documentation regarding medication administration practices. (Continued on LIC 9099) Unsubstantiated (Continued from LIC 9099) An Unusual Incident Report was received by the Regional Office on Monday, July 14, 2025 regarding the medication error. Per Unusual Incident Report, "R2 was placed under close monitoring protocol, with vitals assessed regularly throughout the evening and overnight. No adverse effects were observed." It is noted that R2 remained stable, alert and could communicate needs. A Nurse Practitioner visited R2 the next morning and resident remained stable and at baseline. Therefore, the allegation that staff are not following reporting requirements is Unsubstantiated. LPA reviewed R1,R2 and Resident #3 (R3)'s electronic Medication Administration Records and reviewed resident files. LPA also audited the med cart for all three residents and meds were on cycle, and eMARs were properly initialed. For the resident, R2, who received the wrong medication, it was documented by the nurse, "DNG" which stands for Did Not Give for PM meds. LPA spoke with Nurse regarding medication destruction procedures and meds are destroyed within 24 hours, if not given. Thus there were no extra medications in the med cart for R2. The allegation that staff falsified residents' records is Unsubstantiated. LPA interviewed Residents #1 and Resident #2 while conducting a health and safety check. LPA also interviewed one witness and five of five staff members regarding the incident on the evening of July 13, 2025. 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: Staff are not following reporting requirements and Staff falsified residents' medication records are Unsubstantiated. An exit interview was conducted with Ashiman Gill, Administrator and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jul 22, 2025 · control 22-AS-20250715100345

Allegation investigated: Staff mismanaged residents' medication

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an investigation into a complaint received in our Regional Office. LPA met with Ashiman Gill, Administrator (AD) and explained the purpose of the visit. The purpose of the visit is to investigate an incident on Sunday, July 13, 2025 that staf mismanaged residents' medication. LPA requested the following documents: Staff roster with phone numbers, Current staff schedule, and facility Medication Policy. LPA requested copies of Resident #1 (R1) and Resident #2 (R2)'s: Identification and Emergency Information, Care Plans, Physicians Reports and Medication Administration Records (MARs). LPA also requested to review Staff #1 (S1)'s file and in-service documentation regarding medication administration practices. (Continued on LIC 9099) Substantiated (Continued from LIC 9099) On July 13, 2025 at 5:40pm a nurse from an outside agency was dispensing medication and was preparing the meds on the Med Cart. Staff #1 (S1) offered to assist the nurse and grabbed the prepared meds for Resident #1 (R1) and gave them to Resident #2 (R2). S1 immediately realized the mistake and staff informed AD Gill, the Vice President of Clinical Services, who is a Nurse Practitioner, and the community's Medical Director. The Responsible Party (RP) was also contacted. S1 is not trained to dispense medications and is not a nurse; nor a Medication Technician (Med Tech). The allegation that staff mismanaged residents' medication is Substantiated. LPA interviewed Residents #1 and Resident #2 while conducting a health and safety check. LPA also interviewed one witness and five of five staff members regarding the incident on the evening of July 13, 2025. Upon interviews with staff, R2 was closely monitored throughout the night and vitals were taken three times. S1 also remained by R2's bed until midnight. The Nurse Practitioner also visited resident the next morning and there were no adverse effects and resident remained stable, alert and at baseline. An Unusual Incident Report was also faxed to the Regional Office on July 14, 2025. Based on LPA's record review, observations and interviews, the preponderance of evidence standard has been met, therefore the allegation that staff mismanaged residents' medication is Substantiated. The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Ashiman Gill, Administrator and a copy of this report was given to the facility along with a copy of the Confidential Names LIC 811,LIC 9099-D and Appeal Rights.the state’s words, verbatim · CDSS document, Jul 22, 2025 · control 22-AS-20250715100345

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 23, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on LPA record review and interviews, this requirement was not met for one of one residents which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 22, 2025

Plan of correction: Administrator (AD) conducted an all-staff in-service on July 14-15, 2025 regarding proper Medication Administration procedures and documentation. AD also had a written counseling with Staff #1 on July 16, 2025 regarding clinical role boundaries.

Type of visit: Case Management - Incident

LPA Joseph Alejandre made an unannounced visit to deliver the findings of the investigation into the incident involving Resident 1 (R1) that took place at the facility on December 20, 2024. LPA met with Administrator (AD) Ashiman Gill and explained the reason for the visit. During the course of the investigation, Department staff inspected the facility, interviewed AD, witnesses, and staff, and obtained and reviewed records, staff roster, staff schedule, R1’s emergency contact information, R1’s physician’s report dated November 1, 2023, R1’s resident appraisal dated September 13, 2021, R1’s Physician order review (prescription list), facility surveillance camera footage from December 20, 2024, photographic evidence of R1 from December 21, 2024, Kaiser Permanente medical records dated December 20 to 24, 2024, R1’s after visit summary records dated December 26 and December 31, 2024. The investigation revealed following, The Director of Resident Engagement (DRE) Alyssa Herris led an engagement activity for residents on December 20, 2024, around 3:00 pm. The activity consisted of making a dried resin floral coaster. R1 was one of five participants. Two staff members were present during the activity. There were two bottles of Epoxy Resin (glue) that were mixed and poured in a red solo cup for residents to use in making the coaster. The DRE reported that putting resin in a cup was typical whenever they had a similar activity. The DRE admitted to placing the cup of resin on the table next to R1 and turned away from R1 to redirect another resident. R1 picked up the cup and started to take a few sips. The DRE turned and was facing R1 but was talking to another resident. The DRE saw R1 holding the cup by their mouth, so they went to R1 and took the cup away from R1. This information was verified by surveillance camera footage. R1 then stated, “I don’t want any more of that.” The DRE immediately notified the facility’s Director of Health Services (DHS) Elizabeth Retts. The DRE and DHS gave R1 some water and contacted the Nurse (N1) to assess R1 at 3:27pm. N1 reported that R1’s vital signs were normal. Poison control was called at 3:31 pm. Poison control advised staff to call 911 if R1 fails to eat and drink or if they start vomiting. 10 to 15 minutes later R1 had difficulty talking, became dizzy and R1 started to vomit. Staff called 911 at 3:53 pm. At approximately 4:00 pm the paramedics arrived and R1 was transported to St. Jude Medical Center. R1 was transferred from St. Jude Medical Center to Kaiser Permanente Irvine at 5:18 pm. R1 was hospitalized at Kaiser Permanente from December 20, 2024, to December 24, 2024. R1 suffered chemical burns on their tongue and lips. R1 was diagnosed with Acute hypoxemic respiratory failure and Angioedema (swelling in throat) due to a toxic substance. R1 was prescribed a puree diet, speech therapy and home health visits after their discharge. R1 had follow up appointments on December 26, 2024, and December 31, 2024, to check on their recovery. The facility reported the incident to the Agency on December 21, 2024. R1 was interviewed but could not recall the incident or their hospitalization. R1 ingested a toxic substance that led to Acute hypoxemic respiratory failure and Angioedema (swelling in throat). R1’s physician report shows; R1 has Mild Cognitive Impairment, their mental condition consisted of confusion and disorientation. R1 was noted to being able to follow instructions and communicate their needs. R1’s appraisal and medical records noted R1 has Dementia. The DRE reported that the resin, that was poured in the cup was from 2 different bottles of resin that contained different types of resin. Each bottle of resin had a different warning. Bottle 1 labeled epoxy resin A and bottle 2 labeled epoxy resin B. Bottle 1’s warning states, “causes skin irritation, causes serious eye irritation, may cause an allergic skin reaction, do not get in eyes. Do not get on skin.” Bottle 2’s warning states, “harmful if swallowed, harmful if contact with skin, causes serious eye damage. Do not swallow. Do not get in eyes.” The DRE poured a small amount of resin from each bottle in the cup and then put the cup on a table next to R1. The resin in the cup is a poisonous substance and the cup was unattended as the DRE was attending to another resident when R1 drank from the cup. After the incident R1 was hospitalized. R1 was discharged from the hospital to another facility. During the course of the investigation, the Department obtained sufficient evidence to substantiate, that during the incident the facility failed to ensure that poisonous substances which could pose a danger to residents are not left unattended if outside the locked storage. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division (CCLD) per Health & Safety Code section 1569.49(f). An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Apr 15, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Apr 16, 2025

Type A: 87309(a) – 87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidenced by, based on documents, interviews and video surveillance footage, the licensee did not ensure that poisonous substances are not left unattended if outside the locked storage, as a result R1 suffered chemical burns, Acute hypoxemic respiratory failure and Angioedema (swelling of throat), which poses an immediate health and safety risk to persons in care. CIVIL PENALITY ASSESSED.the state’s words, verbatim · CDSS document, Apr 15, 2025

Plan of correction: Licensee agrees to not use resin in any activity involin any involving residents. Licensee agrees to keep all substances in the above regulation CCR 87309 locked and inaccessible to residents. Licensee agrees to train all staff regarding CCR 87309. Licensee to forward proof to LPA.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Rose Ruppert attempted an unannounced visit on January 15, 2025 at 4:10pm to conduct a Case Management visit. The Regional Office received an Unusual Incident Report on January 10, 2025 regarding a resident elopement. During today's visit the Executive Director (ED) was at a sister community and the Director of Health Services (DHS) was on a scheduled phone call for a family meeting. LPA will return to conduct the Case Management visit at a later date. LPA returned on this date to conduct the Case Management visit. LPA was greeted and granted entry by the receptionist and met with Executive Director (ED), Ashiman Gill. LPA explained the purpose of the visit and requested the following documents: Staffing schedule for Thursday, January 9, 2025, Resident Emergency and Identification Form, Physician's Report and Appraisal. LPA also obtained staff Elopement Drill In-service documents and nurses notes. ED Gill showed LPA the courtyard exit that led to the resident elopement. Resident exited the courtyard door and was visually sighted by the front desk receptionist. Within minutes the Office Service Manager (OSM) and Director of Residents and Engagements (DRE) were with resident and DRE redirected resident back into the community, with assistance from other staff members. The OSM and ED initiated the community's elopement procedures and all staff checked exit doors and did a resident head count to make sure all were secured. Responsible party was notified and the resident was assessed ED provided an Elopement Drill In-service to all staff and it was determined an associate had not completely closed the exit door; while taking out trash and was given associate counseling. The courtyard exit door will now remain locked, with management doing checks daily to make sure the door is closed. Staff were told not to use the courtyard exit to perform job duties and a loud audible alarm was installed on the door, to alert staff if the door is open, the very next day. (Continued on LIC 809-C) (Continued from LIC 809) LPA observed resident participating in group chair exercise and enjoying the workout. Afterwards LPA spoke with resident, who stated, "I'm fine. Everything is okay." LPA thanked the resident for the interview. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Ashiman Gill, Administrator and a copy of the report was given at the time of the visit.the state’s words, verbatim · CDSS document, Jan 16, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced Case Management visit to the facility at 1:45 pm. LPA was greeted and granted entry by the Concierge and met with Ashiman Gill, Administrator (AD) and LIbbie Retts, Director of Health Services (DHS) and stated the purpose of the visit LPA interviewed three of three staff members regarding the Unusual Incident Report received in the Regional Office on December 23, 2024. LPA interviewed two of two resident family members. LPA requested the following resident records: Identification and Emergency Information, Appraisal, Physician's Report, Physician Order Review, and Incident Progress Notes. LPA also requested staff files and the staffing schedule for care staff and engagement staff for December 20, 2024. LPA was also shown video footage of the incident. Based on the interviews and observations made during today’s visit, LPA will need to further investigate the incident. An exit interview was conducted with Ashiman Gill, Administrator and a copy of the report was given at the time of the visit.the state’s words, verbatim · CDSS document, Dec 23, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by the Concierge. During today’s visit, LPA met with Tana McMillon, Administrator (AD) and LIbbie Retts, RN, MSN, Director of Health Services (DHS). The facility is a two story building with an approved fire clearance of seventy non-ambulatory residents of which twenty-five may be bedridden. The facility is divided into two communities. The first level is the Birch community and the second level is the Peppertree community. The facility currently has a census of thirty-seven residents in care. At 8:40 AM LPA toured the facility and spoke with residents in the dining room after breakfast. Staff members were escorting residents to the common areas and to convert the dining room for residents to have a scheduled fitness activity at 9:30 AM. LPA noted the activity would be a zumba class. LPA inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in four of four resident bathrooms, and testing auditory devices on the delayed egress exits in the Birch neighborhood. The hot water temperature measured between 107.0 and 109.4 degrees Fahrenheit and all smoke detectors were operational and were recently tested by Smart Systems Technologies on October 17, 2024. Fire extinguishers throughout the community were charged and serviced on April 2, 2024. The facility’s last fire drill was conducted on October 3, 2024 by Fire Safety Services, Inc.and are done quarterly. LPA observed one of two elevators were out-of-order but Otis Elevators has conducted an inspection and parts are currently being ordered to repair elevator. (Continued on LIC 809-C) (Continued from LIC 809) LPA inspected the facility food supply with the Director of Culinary Services and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. Dietary modifications are in a binder in the kitchen. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. LPA reviewed five of five staff training and fingerprint records and five of five resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on March 10, 2025. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Tana McMillon, Administrator and Libbie Retts, RN, MSN, Director of Health Services and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.the state’s words, verbatim · CDSS document, Oct 18, 2024

Allegation investigated: Facility did not safeguard resident property

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as facility documentation. Regarding the allegation that facility did not safeguard resident property, the investigation revealed the following: Resident was admitted to facility under respite care 05/23/2022-06/01/2022. Per nursing admission evaluation dated 05/23/2022, the resident admitted with hearing aids and evaluation indicated that resident "can hear adequately with devices." Resident was transferred to the hospital and per witness, the hearing aids have not been returned back to responsible party to date. Facility staff is unaware of whereabouts of the hearing aids. Based on interviews conducted and record review, the preponderance of evidence standard has been met. Therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to facility along with appeal rights. Substantiated happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to facility.the state’s words, verbatim · CDSS document, Sep 26, 2024 · control 22-AS-20220614095130

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(12) · Plan of correction due date: Oct 10, 2024

To wear their own clothes; to keep and use their own personal possessions, including their toilet articles; and to keep and be allowed to spend their own money. This req is not being met as evidenced by: Based on interviews conducted and record review, Licensee failed to ensure resident kept their personal possessions. Facility did not retun hearing aids to resident after discharge. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 26, 2024

Plan of correction: Licensee to submit a statement of understanding of the regulation to LPA by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced case management visit to follow up on an Incident Report received in our office on September 18, 2024. LPA was greeted and granted entry by the Concierge at 11AM. LPA met with Ashiman Gill, Administrator (AD) and LIbbie Retts, RN, MSN, CENP, Director of Health Services (DHS). The purpose of the visit is follow-up on an elopement by Resident #1 on September 16, 2024. LPA requested copies of the resident care plan, identification page and medical assessment since records are kept electronically. LPA also requested the staffing schedule for September 16, 2024. LPA noted there were three caregivers on the evening shift (2-10:30PM), one MedTech (10AM-6:30PM) and two charge nurses who overlap (7:30AM-4:00PM) and (2:30-11:00PM) based on facility staffing plan. A recent Care Conference was held on September 12, 2024 prior to the elopement. It is noted in the care plan that the resident is exit seeking but also engages in activities. At 4:45PM resident was not accounted for in the dining room and the elopement procedures were immediately implemented. Staff discovered resident within twenty-five minutes and redirected resident back to the community with no incident. Resident was assessed with no injuries and lab work was initiated to rule out other underlying causes. LPA interviewed resident prior to lunch and was engaged in a crossword puzzle with a 1:1 staff member. Family agreed with AD and DHS recommendations to have more staff rounds in the thirty minutes prior to dinner time. Staff were in-serviced regarding security and safety measures and expectations for the health and safety of the residents in the community. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Ashiman Gill, AD and Libbie Retts, DHS and a copy of the report was given at the time of the visit.the state’s words, verbatim · CDSS document, Sep 24, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced case management visit to follow up on an incident reported to our agency on July 29, 2024. LPA was greeted and granted entry into the facility by Ashiman Gill, Administrator (AD) at 10:30am and explained the reason for the visit. The purpose of today's visit is to follow-up on a self reported incident report received by our Duty Line on July 29, 2024 by Libbie Retts, RN, MSN, CENP, Director of Health Services (DHS). A medication error was reported that Resident #1 (R1) did not receive some medications for three days and medications were discovered by a staff member; who reported to the DHS. DHS immediately contacted physician and responsible party and investigated the incident with staff. Resident was monitored and did not have any effects from not taking the missing medications. Staff in-service training was conducted to prevent a medication incident from happening again. Corrective action was taken. Two of the four involved with the incident are no longer employed by Silverado. LPA requested Medication Administration Record (eMAR) for July 2024, in-service training and July staff roster relating to this incident. LPA interviewed AD Gill and DHS Retts. LPA visited R1 and observed resident engaging in activities. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Ashiman Gill, AD and Libbie Retts, DHS and a copy of the report was given at the time of the visit.the state’s words, verbatim · CDSS document, Sep 9, 2024

Allegation investigated: Staff are not answering resident's call button in a timely manner due to inadequate staffing.

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. Durng the course of the investigation, LPA toured the facility and interviewed staff as well as reviewed and obtained pertinent documentation such as staffing schedule. Regarding the allegation that staff are not answering resident's call button in a timely manner due to inadequate staffing, the investigation revealed the following: LPA interviewed six facility staff as well as Administrator and witness. All interviewed deny any staffing issues and state facility is fully staffed. Facility has an LVN onsite for all shifts as well as four caregivers on first shift, three caregivers on second shift and two caregivers on NOC shift. LPA verified staffing levels with facility schedule and observation. LPA pushed call buttons during the visit and staff responded within 5 minutes. Facility does not have documentation of call button response times. Due to conflicting information, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have CONTINUED ON LIC 9099C DATED 08/08/2024 Unsubstantiated happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to facility.the state’s words, verbatim · CDSS document, Aug 8, 2024 · control 22-AS-20240801130350