Silverado Senior Living - Newport Mesa

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced Case Management visit to the facility on September 13, 2026. Upon arrival, LPA Haddadin met with facility staff Richard Fernando and explained the purpose of the visit. The purpose of the visit was to amend Complaint Control Number 22-AS-20260402150603, specifically the LIC 9099-D deficiency page. An exit interview was conducted with AD Heather Younan. A copy of this Case Management Report, the amended LIC 9099-D, and appeal rights were provided to the Administrator.the state’s words, verbatim · CDSS document, Sep 13, 2026

Allegation investigated: Resident sustained unexplained injuries due to staff neglect or abuse. Staff did not adequately supervise resident in care.

Licensing Program Analyst (LPA) Sam Haddadin conducted an unannounced complaint investigation visit to the facility regarding the above-mentioned allegations. Upon arrival, LPA met with Administrator (AD) Heather Younan who granted entry into the facility. LPA explained the purpose of the visit. During the investigation, the Department conducted interviews and reviewed facility records, internal incident reports, Resident 1 (R1)’s Preplacement Appraisal, Residency Agreement, Service Plan, psychological assessment, photographs, hospital records, and hospice records. Regarding the allegation, “Resident sustained unexplained injuries due to staff neglect or abuse,” facility records documented that R1 was admitted to the facility’s memory care unit in July 2025. R1’s Preplacement Appraisal dated 07/09/2025 identified progressive Alzheimer’s dementia, osteoporosis, significant mobility limitations, and an inability to safely walk more than a few steps without assistance. {****CONTINUE***9099C} Substantiated R1 was identified as non-ambulatory and unstable when walking independently. R1’s Service Plan dated 8/5/2025 stated that R1 required hands-on assistance from staff and might require escorts. The facility’s internal incident reports documented numerous falls, incidents in which R1 was found on the floor, and injuries for which the cause was not always identified. The Department confirmed 12 fall-related incidents between July and December 2025. Several incidents were unwitnessed, and the corresponding reports did not consistently explain how R1 fell or sustained the resulting injuries. In July 2025, staff discovered bruising on R1’s left hand and upper arm without an identified cause. In August 2025, R1 was found sitting on the floor near a reclining chair and was later observed with discoloration and apparent discomfort involving her left hand. Furthermore, in October 2025, R1 was assessed following an unwitnessed incident and was observed with a bump on the back of her head. Several days later, R1 was found on the floor with bruising near her lower left buttock. Staff subsequently observed an unexplained bruise on R1’s left forearm. R1 was later found on the floor with a skin tear to her right elbow. In November 2025, R1 was discovered lying on the floor in a fetal position and was unable to explain how she got there. Staff documented an injury or possible skin tear to R1’s shoulder. R1 was also observed with bruising on her right thigh. During another incident, staff heard a noise and found R1 seated on the floor with her back against a wall and her walker underneath her legs. Another resident reported possibly backing into R1 with a wheelchair. Several days later, R1 attempted to walk around her walker, tripped on the walker’s leg, lost her balance, and fell, resulting in a bump on the back of her head. On December 4, 2025, R1 was found sitting on the floor following another unwitnessed incident. No injuries were initially identified; however, R1 subsequently complained of right arm pain. An X-ray completed the following day revealed a dislocated right shoulder. R1 was transported to the hospital, where additional testing identified a subarachnoid hemorrhage. R1’s shoulder was manually reset, and she remained hospitalized overnight for neurological observation before returning to the facility. Photographs obtained showed multiple injuries and areas of discoloration. {***CONTINUE***9099C} Regarding the allegation, “Facility staff did not adequately supervise R1,” the Department reviewed a psychological assessment completed in October 2025. The assessment documented that R1 required extensive redirection and assistance from two people. The Department interviewed the facility Administrator who confirmed that the facility specialized in memory care and generally assigned one caregiver for every nine residents, in addition to charge nurses assigned to each shift. They acknowledged that R1 experienced a progressive decline and sustained several falls. Staff escorted R1 to and from her room, meals, and activities; however, R1 continued to walk independently with her walker. Administrator confirmed that R1 experienced 12 fall-related incidents between July and December 2025 and stated that following R1’s first fall, the facility provided R1 with a high-low medical bed and placed a fall mat in her room. However, Administrator acknowledged that the facility did not make any additional changes to R1’s treatment or supervision plan following the second fall or any subsequent falls. They also acknowledged that the facility did not formally discuss placing R1 under one-to-one supervision, did not offer the private-duty caregiving option identified in the Residency Agreement, and did not discuss transferring R1 to a higher level of care. S1 further acknowledged that R1 required assistance from two caregivers. Despite R1’s repeated falls, unexplained injuries, and increased need for assistance, the facility did not formally consider these options. Interviews were conducted with R1’s sons who reported conflicting statements about R1’s care received. Per Administrator, R1’s family privately arranged for a caregiver to visit R1 and provide companionship. However, the caregiver’s visits varied, lasted approximately four to five hours, and did not occur every day. Therefore, this arrangement did not provide continuous supervision or replace the facility’s responsibility to develop and implement an appropriate supervision plan. Hospice records documented that R1 began receiving hospice services in December 2025. The records identified repeated falls, wheelchair dependence, and the need for assistance with personal care, and pain related to R1’s right shoulder dislocation. Hospice records stated that R1 could not meaningfully communicate her needs or discomfort and that using a walker had become a safety concern because R1 frequently forgot to use it. {***CONTINUE9099C***} The records further documented that R1 required assistance from two people for transfers. Based on the information obtained during the investigation, the preponderance of evidence standard has been met; therefore, the allegations that “R1 sustained unexplained injuries, due to staff neglect or abuse” and “Facility staff did not adequately supervise R1” are substantiated. An immediate civil penalty was assessed per LIC421IM. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f). Deficiencies are being cited during today’s visit pursuant to Title 22 of the California Code of Regulations. An exit interview was conducted and LIC 811 (Confidential Names) and a copy of this report, along with appeal rights, were provided to AD.the state’s words, verbatim · CDSS document, Aug 25, 2026 · control 22-AS-20260402150603

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Aug 26, 2026

{***THIS IS AN AMENDED REPORT***} “87464(f)(1) Basic services shall at a minimum include care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).” This requirement was not met as evidenced by interviews and record review showing that R1 required significant assistance resulting in multiple fall and right shoulder dislocation and hemorrhage. this poses an immediate health and safety risk to resident in carethe state’s words, verbatim · CDSS document, Aug 25, 2026

Plan of correction: The Administrator will review the care and supervision needs of all current residents with repeated falls or significant changes in condition and update their care plans as needed. Staff will be trained on providing supervision consistent with each resident’s assessed needs. Proof of the completed reviews, updated care plans, and staff training will be submitted to the Department by the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Aug 26, 2026

{***THIS IS AN AMENDED REPORT***} “87466 The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning….” This requirement was not met as evidenced by interviews and record review showing that R1 experienced 12 falls.the presistent frequency and escalation in injury demonstrated inadequate development and implantation of supervision to meet R’1s needs. This possess an immediate health and safety risk to resident in carethe state’s words, verbatim · CDSS document, Aug 25, 2026

Plan of correction: The Administrator will review all current residents for changes in condition and ensure care plans are updated when additional assistance or supervision is needed. Staff will be trained on Section 87466 requirements Proof of the completed reviews and staff training will be submitted to LPA by the POC due date.

Allegation investigated: Medication not being administered as prescribed Staff failed to address a change in resident's health condition

On 07/28/2026, Licensing Program Analyst (LPA) Mikkelson contacted the licensee via email to deliver final findings regarding a complaint that was received on 05/02/2023. **Continued on 9099-C page Unsubstantiated Medication not being administered as prescribed Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff failed to address a change in resident's health condition Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Based on interviews conducted and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 22-AS-20230502140537

Type of visit: Case Management - Health Checks

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Fred Arias for the purpose of a health and safety check. LPA met with Executive Director (ED) Heather Younan and explained the purpose of the inspection. During the inspection, LPA and ED toured the facility. LPA conducted health and safety checks on residents and confirmed they were doing well and observed no health and safety issues. LPA observed the facility clean and organized. LPA observed utility services operational. LPA requested and reviewed copies of resident roster, staff roster, and resident files. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jun 29, 2026

Type of visit: Required - 1 Year

On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. The facility is approved for eighty-two (82) non-ambulatory and hospice waiver for twenty (20) residents. The facility is a two-story structure located in a residential neighborhood. It consists of the following: forty-one (41) resident bedrooms, forty-six (46) bathrooms, four (4) dining areas, kitchen, and outside covered patio area. Residents reside on the first floor only. Administrator (AD) Heather Younan was present to conduct facility tour. AD provided updated liability insurance that expires on 7/1/2026. Around 9:30am LPA toured inside and outside grounds of the physical plant with AD. There were no bodies of water or obstructions on the premises. There is shaded outdoor seating. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Six resident rooms were inspected. Bathrooms were found clean and operational. Toilets and water faucets worked properly, grab bars were secure and showers were free of mold/mildew. The water temperature measured at 106.5 to 116 degrees F. LPA observed the emergency food and water supply. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. The kitchen is inaccessible to residents. Emergency food & water was observed to be adequate. Facility provided documentation dated September 11, 2025 by Lindley Systems stated all smoke detectors, and carbon monoxide detectors were operable. Facility's last conducted Fire/Safety Drill on November 14, 2025. Drills are done quarterly. LPA observed residents participating in activities. First Aid Kit contained all the necessary elements. LPA reviewed six resident files and six staff files. Medications were audited for five residents. Medications are stored in the medication room inside locked carts. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Feb 17, 2026

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility did not implement interventions to prevent residents from eloping.

Licensing Program Analyst (LPA) Jerome Haley made unannounced visit to begin the investigation into the complaint allegation above. LPA Haley was greeted by staff and explained the reason for the visit. Regarding the allegation: Facility did not implement interventions to prevent residents from eloping. During the investigation it was discovered that the complaint allegation was made against the wrong facility. After touring the facility with Staff 1 (S1) documents were requested. Shortly after documents were requested, it was discovered the complaint was indeed filed against the wrong facility. LPA confirmed this by a review of FAS before closing the investigation and informing staff what happened. Based on the information gathered during the pre-investigation and document review, the following allegation above, is deemed Unfounded, meaning the allegation is false and could not have happened. An exit interview was conducted, and a copy of this report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Oct 17, 2025 · control 22-AS-20251010143913

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Fred Arias conducted a Case Management visit to the facility to obtain information pertaining to a self reported incident for an elopement involving resident 1 (R1). R1 eloped the facility and returned to their original residence. The facility submitted the incident report on 09/15/2025. The report indicated that the incident occurred on 09/14/2025. LPA observed various residents throughout the facility. Residents in care appeared to be safe; no imminent health/safety concerns were observed. LPA inspected the inside of facility. Facility appeared to be clean and organized. LPA inspected outside perimeter of facility, to ensure no health/safety hazards were present. The needs of the residents in care appeared to be met during LPA's inspection. LPA obtained copies of pertinent documents and interviewed staff. R1 has not returned since the incident occured and is currently at the hospital. LIC602 physician's report indicates R1 may not leave the facility independently. R1's service plan indicates R1 exhibits wandering behaviors. Interviews with staff revealed elopement behaviors were known and one prior elopement was attempted earlier in the day the same day the R1 eloped. R1 was left alone for approximately 6 minutes during which R1 eloped at approximately 12:48pm. Facility notified law enforcement, responsible party, and DHS, Based on today’s inspection a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at facility along with appeal rights.the state’s words, verbatim · CDSS document, Sep 16, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(e)(5) · Plan of correction due date: Sep 17, 2025

Care Of Persons With Dementia 87705(e)(5) Facility staff shall ensure the continued safety of residents if they wander away from the facility... This requirement is not met as evidence by: Facility did not ensure supervision of resident with continued safety when wandering from the facility. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 16, 2025

Plan of correction: AD stated one on one supervision will be in place when R1 returns. In addition an air tag will be place in R1's show to track location. AD added only associates will supervise R1 and no longer utilize students to supervise.

Type of visit: Required - 1 Year

On this day Licensing Program Analysts (LPAs) Andrea Mendevil and Fred Arias made an unannounced visit to conduct a required annual visit. LPAs were greeted and granted entry into the facility by staff and explained the reason for the visit. The facility is approved for eighty-two (82) non-ambulatory and hospice waiver for twenty (20) residents. The facility is a two-story structure located in a residential neighborhood. It consists of the following: forty-one (41) resident bedrooms, forty-six (46) bathrooms, 4 dining areas, kitchen, and outside covered patio area. Resident reside on the first floor only. Administrator (AD) Heather Younan was present to conduct facility tour. AD provided updated liability insurance that expires on 7/1/2025. Around 9:20am LPAs toured inside and outside grounds of the physical plant with AD Younan. There were no bodies of water or obstructions on the premises. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Five resident’s rooms were inspected. Bathrooms were found clean and operational. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. The water temperature measured at 106.3-121.4 degrees F. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. The kitchen is inaccessible to residents. Emergency food & water was observed to be adequate. Facility provided documentation dated June 4, 2024 by Fire Safety Service confirming all smoke detectors, and carbon monoxide were operable. Facility's last conducted Fire/Safety Drill on January 16, 2025. Drills are done quarterly. LPA's observed Department posters were posted. First Aid Kit contained all the necessary elements. LPAs reviewed five resident files and five staff files. Medications were audited for 5 residents. Medications are stored in the medication room inside locked carts. CONTINUED ON LIC808-C DATED 2/21/2025 Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Feb 21, 2025

Type of visit: Required - 1 Year

On May 10, 2024, at 8:30am, Licensing Program Analysts (LPAs) Jenifer Tirre and Edward Kim conducted an unannounced required 1-year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Tirre and Kim met with Administrator (AD) Heather Younan and explained the purpose of the visit. The facility census is fifty-three (53) residents. The facility is approved for eighty-two (82) non-ambulatory and hospice waiver for twenty (20) residents. The facility is a two-story structure located in a residential neighborhood. It consists of the following: forty-one (41) resident bedrooms, forty-six (46) bathrooms, 4 dining areas, kitchen, and outside covered patio area. Around 9:20am LPAs Tirre and Kim toured inside and outside grounds of the physical plant with AD Younan. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Three resident’s rooms were inspected. Bathrooms were found within Title 22 regulations and were clean and operational. The water temperature measured at 111.2-118.5 degrees F. A comfortable temperature of 68-74 degrees F was maintained in the facility. LPA's observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food & water was observed to be adequate. Three fire extinguishers were checked and all were charged and mounted. Facility provided documentation by Fire Safety Service confirming all smoke detectors, and carbon monoxide were operable during facility's last conducted Fire/Safety Drill on March 6, 2024. Drills are done quarterly. A working telephone (949-631-2212) remains available. Proof of Liability Insurance is valid (7/1/2023-7/1/2024). First Aid Kit contained all the necessary elements. Evaluation Report Continues on LIC 809-C During the visit, LPA's observed the facility's infection control practices. LPA's observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA's observed Department posters were posted. The Administrative Certificate expires June 9, 2025 for Heather Younan. During the visit, LPAs conducted a full audit of all staff files, resident files, and medications. LPAs conducted three (3) resident interviews and six (6) staff interviews. No deficiencies were cited during this inspection visit. An exit interview was conducted, and a copy of this report was provided to Administrator Younan.the state’s words, verbatim · CDSS document, May 10, 2024

Allegation investigated: Staff are not providing adequate care to dementia residents.

Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced subsequent visit to deliver findings for complaint investigation into the above allegations. LPA explained the reason for the visit with Administrator Heather Younan. During the course of the investigation LPA toured facility, conducted interviews, made visual observations and requested pertinent documentation such as Personnel Report, Employee caregiver rounds, resident roster and employee listings. During investigation LPA reviewed facility records such as Personnel report, Employee listings and Care Giver Daily rounds shift schedule dated March 11, 2024. Records reviewed revealed that Facility has 25 Caregivers, eight Licensed Vocational Nurses and two Med Tech’s who provide daily care to residents in facility. Facility records reveal that facility has three scheduled work shifts for staff, a AM shift, a PM shift and a NOC shift. CONTINUED ON 9099C Unsubstantiated Records reveal that on average facility has seven to eight Caregivers in the AM shift, five to six Caregivers in PM shift and three during NOC shift. Records also reveal that facility has on average staffing ratio of 9:1 during AM shift, 11:1 during PM shift and 17:1 during NOC shift. LPA made the following observations during investigation; Facility is a Residential Care Facility for the Elderly that specializes in Memory care. Facility has capacity of 82. During investigation visit on 3/11/24 facility had a census of 51 and on todays date census of 48. During visit on 3/11/24, LPA observed 13 care staff assisting residents in facility. LPA observed that facility is divided into three neighborhoods for residents: Newport, Country Kitchen and Lido. During investigation it was revealed to LPA that staff are assigned to each neighborhood. During visits LPA observed residents relaxing in bedrooms watching TV, relaxing in common area dining rooms eating meals, and being assisted by staff in hallways & outside patio areas. Interviews with staff and residents were conducted and revealed the following, seven of seven staff interviewed stated that facility has three shifts per Caregivers and that caregivers are assigned to one of three neighborhoods inside facility. Interviews with staff revealed that five of five Caregivers stated they assist residents with Activities of Daily Living (ADL’s) such as showering, toileting, making bed’s, dressing, feeding, and transporting. All staff interviewed confirmed that no residents or family members have expressed recent concerns about the quality of care provided to residents. Interviews with Residents revealed that five of five residents stated that they had no complaints about staff members that they like the staff, staff are available when they need, and two of five residents stated that the facility is meeting their care needs. Interview with family witness confirmed that they had no issues with staffing and felt that the level of care was meeting residents needs. Based on observations made by LPA, interviews conducted, and records reviewed 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 following allegations: Staff are not providing adequate care to dementia residents is deemed UNSUBSTANTIATED. An exit interview was conducted with Administrator Heather Younan and a copy of this report was reviewed and provided at the time of this visit.the state’s words, verbatim · CDSS document, Apr 9, 2024 · control 22-AS-20240305090945

Type of visit: Case Management - Incident

This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported incident report received in the Orange County Regional Office (OCRO) on 12/08/23 regarding Resident #1 (R1). LPA met with Staff #1 (S1) Jannette Cervantes and discussed the purpose of the inspection. Administrator (AD) Heather Younan appeared via telephone. The incident report states that on 12/04/23, R1 was given 2 tabs of Tramadol in the evening instead of 1 tab, the error was noticed immediately, R1’s doctor and family were notified, and R1 was observed for any reactions. During today’s inspection, LPA toured the facility with S1, inspected the medication room, conducted a health and safety check on R1, confirmed R1 was doing well, and observed no health and safety issues. LPA interviewed AD who provided the following information. R1’s doctor advised the facility to monitor R1 closely for 2 hours and that if there was no reaction then no medical treatment would be necessary. R1 was monitored and did not have a reaction and is doing fine. Based on the information obtained during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. 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, Dec 15, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 5, 2024

87465 Incidental Medical and Dental Care. (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interview and documents, the licensee did not ensure R1 received assistance with self-administered medications due to a medication error, which posed a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Dec 15, 2023

Plan of correction: Licensee stated they will provide additional training to all Medication Technicians and submit proof to LPA by POC due date.